Provider Demographics
NPI:1346889433
Name:COPPERSMITH, KEELA (LPC-IT)
Entity Type:Individual
Prefix:
First Name:KEELA
Middle Name:
Last Name:COPPERSMITH
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5524
Mailing Address - Country:US
Mailing Address - Phone:414-526-3592
Mailing Address - Fax:
Practice Address - Street 1:631 FOREST ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5524
Practice Address - Country:US
Practice Address - Phone:715-842-0944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4553-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional