Provider Demographics
NPI:1083396683
Name:KOPACZ, ZACHARY DANIEL
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:DANIEL
Last Name:KOPACZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W4874 EDELWEISS RD
Mailing Address - Street 2:
Mailing Address - City:NEW GLARUS
Mailing Address - State:WI
Mailing Address - Zip Code:53574-9304
Mailing Address - Country:US
Mailing Address - Phone:608-424-8735
Mailing Address - Fax:
Practice Address - Street 1:W4874 EDELWEISS RD
Practice Address - Street 2:
Practice Address - City:NEW GLARUS
Practice Address - State:WI
Practice Address - Zip Code:53574-9304
Practice Address - Country:US
Practice Address - Phone:608-424-8735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician