Provider Demographics
NPI:1710661822
Name:KOPPELA-SUTHERLAND, STUART (LLC)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:KOPPELA-SUTHERLAND
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 LEVEE ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2252
Mailing Address - Country:US
Mailing Address - Phone:248-802-9685
Mailing Address - Fax:
Practice Address - Street 1:4000 W WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4191
Practice Address - Country:US
Practice Address - Phone:248-461-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022847101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor