1174992390 NPI number — DR. SARAH LYNN KOPELOVICH PHD

Table of content: DR. SARAH LYNN KOPELOVICH PHD (NPI 1174992390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174992390 NPI number — DR. SARAH LYNN KOPELOVICH PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOPELOVICH
Provider First Name:
SARAH
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174992390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 50095
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98145-5095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-520-5708
Provider Business Mailing Address Fax Number:
206-685-3430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98122-2499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-744-9854
Provider Business Practice Location Address Fax Number:
206-685-3430
Provider Enumeration Date:
09/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY60589526 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1174992390 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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