Provider Demographics
NPI:1366682783
Name:COPPLE, DEBRA (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:COPPLE
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3983
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-3983
Mailing Address - Country:US
Mailing Address - Phone:863-409-2994
Mailing Address - Fax:863-438-7064
Practice Address - Street 1:244 E PARK AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3706
Practice Address - Country:US
Practice Address - Phone:863-409-2994
Practice Address - Fax:863-438-7064
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003766235Z00000X
FLSA5861235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000655600Medicaid
CO9000177366Medicaid