Provider Demographics
NPI:1225366883
Name:KOPPIN, MALIA RENEE (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:MALIA
Middle Name:RENEE
Last Name:KOPPIN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 GORE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-1213
Mailing Address - Country:US
Mailing Address - Phone:937-726-7222
Mailing Address - Fax:
Practice Address - Street 1:77 GORE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1213
Practice Address - Country:US
Practice Address - Phone:937-726-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRY829499OtherDRIVER'S LICENSE