Provider Demographics
NPI:1316103245
Name:KOPITZKE, BETH ELLEN (OTA)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ELLEN
Last Name:KOPITZKE
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 ALDERSON ST
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-3614
Mailing Address - Country:US
Mailing Address - Phone:715-359-4257
Mailing Address - Fax:
Practice Address - Street 1:6001 ALDERSON ST
Practice Address - Street 2:
Practice Address - City:SCHOFIELD
Practice Address - State:WI
Practice Address - Zip Code:54476-3614
Practice Address - Country:US
Practice Address - Phone:715-359-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI105-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40563900Medicaid