Provider Demographics
NPI:1063634699
Name:COPPOCK, BETHANY DAWN (COTA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:DAWN
Last Name:COPPOCK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S BARCLAY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:IN
Mailing Address - Zip Code:46928
Mailing Address - Country:US
Mailing Address - Phone:765-251-1531
Mailing Address - Fax:
Practice Address - Street 1:4725 COLONIAL OAKS DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953
Practice Address - Country:US
Practice Address - Phone:765-674-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001358A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant