Healthcare Provider Details

I. General information

NPI: 1215240395
Provider Name (Legal Business Name): KRISTIN KOPPLE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2010
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 WALNUT ST STE 1700
PHILADELPHIA PA
19107-4717
US

IV. Provider business mailing address

1315 WALNUT ST STE 1700
PHILADELPHIA PA
19107-4717
US

V. Phone/Fax

Practice location:
  • Phone: 215-850-3490
  • Fax: 215-545-8496
Mailing address:
  • Phone: 215-850-3490
  • Fax: 215-545-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS018288
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: