Provider Demographics
NPI:1326651043
Name:COPELAND, DESSIRAE
Entity Type:Individual
Prefix:
First Name:DESSIRAE
Middle Name:
Last Name:COPELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13611 PERRY RD APT 4102
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4584
Mailing Address - Country:US
Mailing Address - Phone:405-889-2904
Mailing Address - Fax:
Practice Address - Street 1:16597 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:JERSEY VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:77040-1124
Practice Address - Country:US
Practice Address - Phone:713-574-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TX103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician