Provider Demographics
NPI:1952032922
Name:KOPPERUD, GRETA (BA)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:KOPPERUD
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5851 E MAYFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7881
Mailing Address - Country:US
Mailing Address - Phone:907-376-4000
Mailing Address - Fax:
Practice Address - Street 1:5851 E MAYFLOWER CT
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7881
Practice Address - Country:US
Practice Address - Phone:907-376-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health