Provider Demographics
NPI:1144978404
Name:KOEPPEL, TAISIA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:TAISIA
Middle Name:LYNN
Last Name:KOEPPEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 S FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-6392
Mailing Address - Country:US
Mailing Address - Phone:973-509-9777
Mailing Address - Fax:
Practice Address - Street 1:33 S FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-6392
Practice Address - Country:US
Practice Address - Phone:973-509-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC056596001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical