Provider Demographics
NPI:1518667104
Name:VANCOPPENOLLE, KANDISS
Entity Type:Individual
Prefix:
First Name:KANDISS
Middle Name:
Last Name:VANCOPPENOLLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 S INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-9175
Mailing Address - Country:US
Mailing Address - Phone:734-944-3446
Mailing Address - Fax:
Practice Address - Street 1:196 S INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-9175
Practice Address - Country:US
Practice Address - Phone:734-944-3446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011113811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical