Provider Demographics
NPI:1003967381
Name:KOPACK, KEVIN N (MSPT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:N
Last Name:KOPACK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CUPSAW AVE
Mailing Address - Street 2:
Mailing Address - City:RINGWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07456-2919
Mailing Address - Country:US
Mailing Address - Phone:973-962-6568
Mailing Address - Fax:
Practice Address - Street 1:271 US HIGHWAY 46
Practice Address - Street 2:SUITE G106 - FAIRFIELD COMMONS
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2440
Practice Address - Country:US
Practice Address - Phone:973-276-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJQA03353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist