Provider Demographics
NPI:1962852970
Name:KOPACKI, MARY (MS, LAT, ATC, PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KOPACKI
Suffix:
Gender:F
Credentials:MS, LAT, ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CRAPE MYRTLE CIR
Mailing Address - Street 2:
Mailing Address - City:BROWNS SUMMIT
Mailing Address - State:NC
Mailing Address - Zip Code:27214-9460
Mailing Address - Country:US
Mailing Address - Phone:561-596-2870
Mailing Address - Fax:
Practice Address - Street 1:7 CRAPE MYRTLE CIR
Practice Address - Street 2:
Practice Address - City:BROWNS SUMMIT
Practice Address - State:NC
Practice Address - Zip Code:27214-9460
Practice Address - Country:US
Practice Address - Phone:561-596-2870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT1595171W00000X
FLAL1739171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor