Provider Demographics
NPI:1053565663
Name:COPPOLA, KELLY ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:COPPOLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MONTROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:3177 30TH ST
Mailing Address - Street 2:APT 3
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2801
Mailing Address - Country:US
Mailing Address - Phone:646-457-1227
Mailing Address - Fax:
Practice Address - Street 1:1133 BROADWAY
Practice Address - Street 2:SUITE 1107
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7903
Practice Address - Country:US
Practice Address - Phone:646-457-1227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720769371041C0700X
NY0789631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical