Provider Demographics
NPI:1093171266
Name:KOOPMAN, DALE (MT)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:KOOPMAN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 W LUCERNE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2623
Mailing Address - Country:US
Mailing Address - Phone:970-799-7012
Mailing Address - Fax:
Practice Address - Street 1:507 W LUCERNE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2623
Practice Address - Country:US
Practice Address - Phone:970-799-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0018263225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist