Basic Information
| Provider Information | |||||||||
| NPI: | 1861731556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COPPOLA | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 436A FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115504212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162927111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 PRESIDENT ST | ||||||||
| Address2: | |||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115504718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162927111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2013 | ||||||||
| LastUpdateDate: | 01/31/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 003091 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 003091 | 05 | NY | MEDICAID |