Provider Demographics
NPI:1326660879
Name:VANKOPPEN, MICHAEL (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VANKOPPEN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BOGERT RD
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9726
Mailing Address - Country:US
Mailing Address - Phone:973-618-6738
Mailing Address - Fax:
Practice Address - Street 1:1040 ORADELL AVE
Practice Address - Street 2:
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649-1954
Practice Address - Country:US
Practice Address - Phone:201-261-1844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002703002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer