Provider Demographics
NPI:1386739597
Name:KOEPPL, GINA K (PHD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:K
Last Name:KOEPPL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-8360
Mailing Address - Country:US
Mailing Address - Phone:715-361-2000
Mailing Address - Fax:715-361-2877
Practice Address - Street 1:2251 N SHORE DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-8360
Practice Address - Country:US
Practice Address - Phone:715-361-2000
Practice Address - Fax:715-361-2877
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1240103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39040400Medicaid
WI39040400Medicaid