Provider Demographics
NPI:1912246760
Name:KOPPEL, PAMELA SUSAN (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUSAN
Last Name:KOPPEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7613 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3625
Mailing Address - Country:US
Mailing Address - Phone:707-799-2203
Mailing Address - Fax:
Practice Address - Street 1:175 CONCOURSE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8217
Practice Address - Country:US
Practice Address - Phone:707-284-9235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS191761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical