Provider Demographics
NPI:1700051117
Name:KOOP, HEIDEMARIE
Entity Type:Individual
Prefix:
First Name:HEIDEMARIE
Middle Name:
Last Name:KOOP
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 1:75-5744 ALII DR 237
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1740
Mailing Address - Country:US
Mailing Address - Phone:808-987-2296
Mailing Address - Fax:877-585-5099
Practice Address - Street 1:81-6161 D ROAD
Practice Address - Street 2:
Practice Address - City:CAPTAIN COOK
Practice Address - State:HI
Practice Address - Zip Code:96704
Practice Address - Country:US
Practice Address - Phone:808-987-2296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW - 32681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical