Provider Demographics
NPI:1275784548
Name:COPENHAGEN, HOLLY JANE (PT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JANE
Last Name:COPENHAGEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 GRACE ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-4600
Mailing Address - Country:US
Mailing Address - Phone:503-882-4384
Mailing Address - Fax:
Practice Address - Street 1:525 N SANTIAM HWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-4363
Practice Address - Country:US
Practice Address - Phone:541-451-7125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5758225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist