MEDICARE: KRISTIE JO COPPEDGE LMHC, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LH00006307	WA
2	1041C0700X	Clinical Social Worker	LW00007408	WA

General Provider Information

NPI Number	:	1093850224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIE JO COPPEDGE LMHC, LICSW

Provider Business Mailing Address
First Line	:	20102 CEDAR VALLEY RD
Second Line	:	SUITE 104
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-6333
Country	:	US
Telephone Number	:	425-670-2102
Fax Number	:	425-670-8081

Provider Business Practice Location Address
First Line	:	20102 CEDAR VALLEY RD
Second Line	:	SUITE 104
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-6333
Country	:	US
Telephone Number	:	425-670-2102
Fax Number	:	425-670-8081

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	08/28/2007

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