Provider Demographics
NPI:1326463944
Name:KOPACEK, HEIDI (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:
Last Name:KOPACEK
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11280 86TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4510
Mailing Address - Country:US
Mailing Address - Phone:763-400-7828
Mailing Address - Fax:763-400-7444
Practice Address - Street 1:11280 86TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4510
Practice Address - Country:US
Practice Address - Phone:763-400-7828
Practice Address - Fax:763-400-7444
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5712103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400137738OtherMEDICARE PTAN
MN1326463944Medicaid
MN1326463944Medicaid