Provider Demographics
NPI:1093850224
Name:COPPEDGE, KRISTIE JO (LMHC, LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:JO
Last Name:COPPEDGE
Suffix:
Gender:F
Credentials:LMHC, LICSW
Other - Prefix:
Other - First Name:KRIS
Other - Middle Name:
Other - Last Name:COPPEDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC, LICSW
Mailing Address - Street 1:20102 CEDAR VALLEY RD
Mailing Address - Street 2:SUITE 104
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 104
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006307101YM0800X
WALW000074081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical