Healthcare Provider Details

I. General information

NPI: 1083936546
Provider Name (Legal Business Name): MISS MELINDA KOPECKY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 VINE HILL RD
SEBASTOPOL CA
95472-2237
US

IV. Provider business mailing address

4740 VINE HILL RD
SEBASTOPOL CA
95472-2237
US

V. Phone/Fax

Practice location:
  • Phone: 650-464-1426
  • Fax:
Mailing address:
  • Phone: 650-464-1426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number7252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: