Provider Demographics
NPI:1043521297
Name:KOOPERKAMP, ELIZABETH B (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:B
Last Name:KOOPERKAMP
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:B
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:390 RIVER ST.
Mailing Address - Street 2:HCRS
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2226
Mailing Address - Country:US
Mailing Address - Phone:802-886-4500
Mailing Address - Fax:802-886-4520
Practice Address - Street 1:49 SCHOOL ST.
Practice Address - Street 2:HCRS
Practice Address - City:HARTFORD
Practice Address - State:VT
Practice Address - Zip Code:05047-0709
Practice Address - Country:US
Practice Address - Phone:802-295-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012558-1101YM0800X
VT048.0093460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health