Provider Demographics
NPI:1619776101
Name:KOPP, JUSTINE (ATRL-BC)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:KOPP
Suffix:
Gender:F
Credentials:ATRL-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 NIESEN RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1358
Mailing Address - Country:US
Mailing Address - Phone:262-227-6391
Mailing Address - Fax:
Practice Address - Street 1:548 S PARK ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2124
Practice Address - Country:US
Practice Address - Phone:262-227-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67-36221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist