Provider Demographics
NPI:1609584622
Name:SCHULTZ, COPELIN
Entity Type:Individual
Prefix:
First Name:COPELIN
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 NE EVANGELINE TRWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-2554
Mailing Address - Country:US
Mailing Address - Phone:337-534-8679
Mailing Address - Fax:
Practice Address - Street 1:3420 NE EVANGELINE TRWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-2554
Practice Address - Country:US
Practice Address - Phone:337-534-8679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-667103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAL-667OtherLBA LICENSE