=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760921134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIPPENSTEEL, JACOB, & KOPPE THERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2017
-----------------------------------------------------
Last Update Date | 02/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 RIDGE AVE
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-5918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-778-5115
-----------------------------------------------------
Fax | 312-778-5256
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8125 LOWELL AVE
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60076-3213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-778-5116
-----------------------------------------------------
Fax | 312-778-5254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | CHRISTINE KOPPE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 312-778-5117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180009167
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149010925
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149011193
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------