Provider Demographics
NPI:1083995740
Name:COPPEDGE PSYCHOTHERAPY INC
Entity Type:Organization
Organization Name:COPPEDGE PSYCHOTHERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:JO
Authorized Official - Last Name:COPPEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:425-670-2102
Mailing Address - Street 1:20102 CEDAR VALLEY RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6333
Mailing Address - Country:US
Mailing Address - Phone:425-670-2102
Mailing Address - Fax:425-670-8081
Practice Address - Street 1:20102 CEDAR VALLEY RD
Practice Address - Street 2:SUITE 107
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6333
Practice Address - Country:US
Practice Address - Phone:425-670-2102
Practice Address - Fax:425-670-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00007408251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health