Provider Demographics
NPI:1508424458
Name:COPELAND, MISTY MYRICK (COTA/L)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MYRICK
Last Name:COPELAND
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 KEEN RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30747-6379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:318 KEEN RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30747-6379
Practice Address - Country:US
Practice Address - Phone:706-857-8890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001260224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant