Basic Information
| Provider Information | |||||||||
| NPI: | 1356691141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOOPERMAN | ||||||||
| FirstName: | KATE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 ATLANTIC PL | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078427708 | ||||||||
| FaxNumber: | 2078427773 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 UNION ST | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 048412739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077014400 | ||||||||
| FaxNumber: | 2077014485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2012 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 115911 | MA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LC14273 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1303414 | 05 | MA | MEDICAID |