Provider Demographics
NPI:1174942296
Name:COPPAGE, MICHELLE DIANE (MS, PC)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:DIANE
Last Name:COPPAGE
Suffix:
Gender:F
Credentials:MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 CLIFTMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-1909
Mailing Address - Country:US
Mailing Address - Phone:410-488-8674
Mailing Address - Fax:
Practice Address - Street 1:3437 CLIFTMONT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1909
Practice Address - Country:US
Practice Address - Phone:410-488-8674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional