Provider Demographics
NPI:1003268509
Name:KOEPKE, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:KOEPKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7461
Mailing Address - Country:US
Mailing Address - Phone:716-634-0627
Mailing Address - Fax:716-634-0746
Practice Address - Street 1:8616 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7461
Practice Address - Country:US
Practice Address - Phone:716-634-0627
Practice Address - Fax:716-634-0746
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY024762103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program