Basic Information
| Provider Information | |||||||||
| NPI: | 1386739597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOEPPL | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2251 N SHORE DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545018360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153612000 | ||||||||
| FaxNumber: | 7153612877 | ||||||||
| Practice Location | |||||||||
| Address1: | 2251 N SHORE DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545018360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153612000 | ||||||||
| FaxNumber: | 7153612877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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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 | 103TC0700X | 1240 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 1240 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 39040400 | 05 | WI | MEDICAID |