Provider Demographics
NPI:1396423950
Name:KOPPENDRAYER, MIKAYLA JOY
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:JOY
Last Name:KOPPENDRAYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:JOY
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1994 E RUM RIVER DR S
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-2663
Mailing Address - Country:US
Mailing Address - Phone:763-689-5385
Mailing Address - Fax:763-328-2782
Practice Address - Street 1:1994 E RUM RIVER DR S
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-2663
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:763-328-2782
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician