Provider Demographics
NPI:1679073191
Name:KOEPKE, VANITA UPENDRA (DPT)
Entity Type:Individual
Prefix:
First Name:VANITA
Middle Name:UPENDRA
Last Name:KOEPKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:VANITA
Other - Middle Name:UPENDRA
Other - Last Name:SHUKLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-541-3735
Practice Address - Street 1:26025 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033
Practice Address - Country:US
Practice Address - Phone:248-663-2192
Practice Address - Fax:248-663-1901
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016335225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist