Provider Demographics
NPI:1093929200
Name:COPELAND, MARK BRADLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRADLEY
Last Name:COPELAND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 WILSHIRE BLVD STE 660
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4746
Mailing Address - Country:US
Mailing Address - Phone:310-968-2668
Mailing Address - Fax:
Practice Address - Street 1:2730 WILSHIRE BLVD STE 660
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4746
Practice Address - Country:US
Practice Address - Phone:310-968-2668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18589103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical