Provider Demographics
NPI:1679697908
Name:KOPACK, BRIAN WILLIAM (MA LPC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIAM
Last Name:KOPACK
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:07720-1204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 S 3RD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:08904-2510
Practice Address - Country:US
Practice Address - Phone:732-246-8439
Practice Address - Fax:732-246-8081
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PCOO351200101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor