Provider Demographics
NPI:1447281357
Name:KOPPENHAVER, JOHN H IV (MA, LCP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:H
Last Name:KOPPENHAVER
Suffix:IV
Gender:M
Credentials:MA, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 N EDGEMOOR ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-4420
Mailing Address - Country:US
Mailing Address - Phone:316-684-3688
Mailing Address - Fax:316-684-7249
Practice Address - Street 1:217 W IRA CT
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-9469
Practice Address - Country:US
Practice Address - Phone:316-733-5047
Practice Address - Fax:316-733-5060
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCP 248103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist