Provider Demographics
NPI:1184213050
Name:KOPPELMANN, MYRIAM LIBERTY
Entity Type:Individual
Prefix:MS
First Name:MYRIAM
Middle Name:LIBERTY
Last Name:KOPPELMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 MARINA CITY DR # 947ETN
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5813
Mailing Address - Country:US
Mailing Address - Phone:310-435-5003
Mailing Address - Fax:
Practice Address - Street 1:4337 MARINA CITY DR # 947ETN
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5813
Practice Address - Country:US
Practice Address - Phone:310-435-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73597225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty