Provider Demographics
NPI:1346566122
Name:KOPPENHAVER, PAUL LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:LEE
Last Name:KOPPENHAVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 E NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2340
Mailing Address - Country:US
Mailing Address - Phone:800-981-4357
Mailing Address - Fax:617-414-8306
Practice Address - Street 1:85 E NEWTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2340
Practice Address - Country:US
Practice Address - Phone:800-981-4357
Practice Address - Fax:617-414-8306
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA284419101YM0800X, 101YS0200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool