Provider Demographics
NPI:1508273764
Name:COPPOCK-WEBB, KATHLEEN (LSW, CSW INTERN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:COPPOCK-WEBB
Suffix:
Gender:F
Credentials:LSW, CSW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-5340
Mailing Address - Country:US
Mailing Address - Phone:702-884-8495
Mailing Address - Fax:
Practice Address - Street 1:222 S RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-5340
Practice Address - Country:US
Practice Address - Phone:702-884-8495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIC-14821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical