Healthcare Provider Details

I. General information

NPI: 1093850224
Provider Name (Legal Business Name): KRISTIE JO COPPEDGE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRIS COPPEDGE LICSW

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 1/2 E 1ST ST
PORT ANGELES WA
98362-2929
US

IV. Provider business mailing address

105 1/2 E 1ST ST
PORT ANGELES WA
98362-2929
US

V. Phone/Fax

Practice location:
  • Phone: 360-797-3564
  • Fax:
Mailing address:
  • Phone: 360-797-3564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00007408
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: