Provider Demographics
NPI:1053583120
Name:KOPOLOW, MINDY SUE (MA, PSYD)
Entity type:Individual
Prefix:DR
First Name:MINDY
Middle Name:SUE
Last Name:KOPOLOW
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W CUMMINGS PARK
Mailing Address - Street 2:SUITE 3400
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-6519
Mailing Address - Country:US
Mailing Address - Phone:617-972-5055
Mailing Address - Fax:617-972-5011
Practice Address - Street 1:400 W CUMMINGS PARK
Practice Address - Street 2:SUITE 3400
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6519
Practice Address - Country:US
Practice Address - Phone:617-972-5055
Practice Address - Fax:617-972-5011
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-29
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA851101YM0800X
MA8603103TC0700X
FLPY5819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54439OtherBCBS OF FLORIDA
FL54439Medicare PIN