Provider Demographics
NPI:1578304747
Name:KOPPERS, MADDELYN ROSE
Entity type:Individual
Prefix:
First Name:MADDELYN
Middle Name:ROSE
Last Name:KOPPERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 HAMILTON ROAD
Mailing Address - Street 2:SUIT #217
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864
Mailing Address - Country:US
Mailing Address - Phone:517-295-3175
Mailing Address - Fax:
Practice Address - Street 1:2190 HAMILTON ROAD
Practice Address - Street 2:SUIT #217
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864
Practice Address - Country:US
Practice Address - Phone:517-295-3175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician