Provider Demographics
NPI:1578587432
Name:COPELAND, TERRY FRED (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:FRED
Last Name:COPELAND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 5TH AVE S
Mailing Address - Street 2:APT 10
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-4039
Mailing Address - Country:US
Mailing Address - Phone:425-361-7670
Mailing Address - Fax:425-967-5572
Practice Address - Street 1:6912 220TH ST SW
Practice Address - Street 2:SUITE 113
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2169
Practice Address - Country:US
Practice Address - Phone:425-361-7670
Practice Address - Fax:425-967-5572
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600 559 777103T00000X
WAPY00000801103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB20740Medicare PIN
WAAB20740Medicare ID - Type UnspecifiedPSYCHOLOGY