Provider Demographics
NPI:1538832514
Name:KOPACZ, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KOPACZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:TUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:84 W BROADWAY STE 200
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2323
Mailing Address - Country:US
Mailing Address - Phone:603-505-8133
Mailing Address - Fax:
Practice Address - Street 1:235 HANOVER ST STE 5
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-6138
Practice Address - Country:US
Practice Address - Phone:603-505-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2215741041C0700X
MA1246671041C0700X
NH27621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical