Provider Demographics
NPI:1225587991
Name:KOPAC, BREONNA
Entity Type:Individual
Prefix:
First Name:BREONNA
Middle Name:
Last Name:KOPAC
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 1:1300 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:PA
Mailing Address - Zip Code:15042-1808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 5TH AVE
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:PA
Practice Address - Zip Code:15042
Practice Address - Country:US
Practice Address - Phone:724-630-4073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-16-22692103K00000X
101YM0800X, 103K00000X, 106S00000X
PABH005775103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician