Provider Demographics
NPI:1851904676
Name:KOPERSKI, CHEYENNE
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:
Last Name:KOPERSKI
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 1:438 EDDIE LN
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3425
Mailing Address - Country:US
Mailing Address - Phone:707-823-8722
Mailing Address - Fax:
Practice Address - Street 1:438 EDDIE LN
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3425
Practice Address - Country:US
Practice Address - Phone:707-823-8722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 390200000X, 101Y00000X
CA120627104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor