Provider Demographics
NPI:1881865426
Name:KOPPANG, TERESA RAE (MS CCCSLP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:RAE
Last Name:KOPPANG
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1044
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631-1044
Mailing Address - Country:US
Mailing Address - Phone:952-240-0551
Mailing Address - Fax:
Practice Address - Street 1:38100 ANTLER LN
Practice Address - Street 2:
Practice Address - City:BATTLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:56515-9270
Practice Address - Country:US
Practice Address - Phone:952-240-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8187235Z00000X
WALL60762859235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist