Provider Demographics
NPI:1407035959
Name:KOEPNICK, SUSAN L (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:KOEPNICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 WAUNA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-3447
Mailing Address - Country:US
Mailing Address - Phone:208-731-1711
Mailing Address - Fax:208-678-3556
Practice Address - Street 1:2311 PARK AVE
Practice Address - Street 2:UNIT 3 SUITE 12
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2170
Practice Address - Country:US
Practice Address - Phone:208-678-3555
Practice Address - Fax:208-678-3556
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3103101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC-3103OtherSTATE OF IDAHO