Healthcare Provider Details

I. General information

NPI: 1609173814
Provider Name (Legal Business Name): KATHYRN DAWN KOPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

996 WILLOWBROOK CT
WINTER HAVEN FL
33884-2940
US

IV. Provider business mailing address

996 WILLOWBROOK CT
WINTER HAVEN FL
33884-2940
US

V. Phone/Fax

Practice location:
  • Phone: 863-324-7458
  • Fax: 863-519-7559
Mailing address:
  • Phone: 863-324-7458
  • Fax: 863-519-7559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: