Provider Demographics
NPI:1871929729
Name:OLD DOMINION UNIVERSITY
Entity type:Organization
Organization Name:OLD DOMINION UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOPERNA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:757-683-7041
Mailing Address - Street 1:1019 W 41ST ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23529-0001
Mailing Address - Country:US
Mailing Address - Phone:757-683-7041
Mailing Address - Fax:757-683-4410
Practice Address - Street 1:1019 W 41ST ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23529-0001
Practice Address - Country:US
Practice Address - Phone:757-683-7041
Practice Address - Fax:757-683-4410
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLD DOMINION UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-24
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty