Provider Demographics
NPI:1801404900
Name:KOEPFGEN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KOEPFGEN
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 1:351 OLD LIMESTONE RD W
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-8386
Mailing Address - Country:US
Mailing Address - Phone:803-762-5279
Mailing Address - Fax:
Practice Address - Street 1:900 BRANCHVIEW DR NE STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2226
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:888-261-6694
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician