Provider Demographics
NPI:1639558778
Name:COPPLE, MATT (PHR)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:COPPLE
Suffix:
Gender:M
Credentials:PHR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-0043
Mailing Address - Country:US
Mailing Address - Phone:425-358-4644
Mailing Address - Fax:425-947-9844
Practice Address - Street 1:26625 225TH AVE SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-7448
Practice Address - Country:US
Practice Address - Phone:206-948-5354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIHS.FS.60506716253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAIHS.FS.60606716OtherDEPARTMENT OF HEALTH