Provider Demographics
NPI:1043775687
Name:COPELAND, BREONNA NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:BREONNA
Middle Name:NICOLE
Last Name:COPELAND
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8877 LAKES AT 610 DR APT 270
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2579
Mailing Address - Country:US
Mailing Address - Phone:254-289-2843
Mailing Address - Fax:
Practice Address - Street 1:8877 LAKES AT 610 DR APT 270
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2579
Practice Address - Country:US
Practice Address - Phone:254-289-2843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66048104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX41021054OtherMICHAEL E DEBAKEY VETERAN'S AFFAIRS HOSPITAL