Provider Demographics
NPI:1619231404
Name:KOPPE, MARIANNE (MSED)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:KOPPE
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 RALPH AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4421
Mailing Address - Country:US
Mailing Address - Phone:516-992-8986
Mailing Address - Fax:
Practice Address - Street 1:3136 RALPH AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-4421
Practice Address - Country:US
Practice Address - Phone:516-992-8986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist