Provider Demographics
NPI:1538458302
Name:KOPKA, SUSAN J (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:KOPKA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 155
Mailing Address - Street 2:10953 E POBUDA RD
Mailing Address - City:OMENA
Mailing Address - State:MI
Mailing Address - Zip Code:49674
Mailing Address - Country:US
Mailing Address - Phone:231-883-2738
Mailing Address - Fax:
Practice Address - Street 1:1200 W. 11TH ST. SUITE 113
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-883-2738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010852841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical