Provider Demographics
NPI:1346003480
Name:COPELAND-SHUFF, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:COPELAND-SHUFF
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 1:103 E PEPPERMINT ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45390-1912
Mailing Address - Country:US
Mailing Address - Phone:937-423-1256
Mailing Address - Fax:
Practice Address - Street 1:600 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1944
Practice Address - Country:US
Practice Address - Phone:937-548-6842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-01
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OHAPS.004812175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist