Healthcare Provider Details

I. General information

NPI: 1952188344
Provider Name (Legal Business Name): CASSANDRA JAYNE KOPPELMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASSIE FOSDICK

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W231N1440 CORPORATE CT
WAUKESHA WI
53186-1503
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-773-4312
  • Fax: 262-896-6139
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number132797-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: