Provider Demographics
NPI:1699096511
Name:KOPENHAVER, KIMBERLY ANN (LMFT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:KOPENHAVER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 INDEPENDENCE PKWY STE 311-171
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-9152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 INDEPENDENCE PKWY STE 311-171
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-9152
Practice Address - Country:US
Practice Address - Phone:682-253-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46739106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL