Provider Demographics
NPI:1437578622
Name:COPELAND, RAPHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:COPELAND
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10233 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-2518
Mailing Address - Country:US
Mailing Address - Phone:708-938-5238
Mailing Address - Fax:708-938-5239
Practice Address - Street 1:10001 DERBY LN
Practice Address - Street 2:SUITE 208
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-3749
Practice Address - Country:US
Practice Address - Phone:708-681-2991
Practice Address - Fax:708-938-5239
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006704174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist