Provider Demographics
NPI:1942763396
Name:COPELAND, THERESA MAY
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MAY
Last Name:COPELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14922 GLASTONBURY DR
Mailing Address - Street 2:
Mailing Address - City:GOWEN
Mailing Address - State:MI
Mailing Address - Zip Code:49326-9459
Mailing Address - Country:US
Mailing Address - Phone:616-302-9035
Mailing Address - Fax:
Practice Address - Street 1:4735 W RANGER RD
Practice Address - Street 2:
Practice Address - City:PERRINTON
Practice Address - State:MI
Practice Address - Zip Code:48871-9775
Practice Address - Country:US
Practice Address - Phone:989-236-3599
Practice Address - Fax:989-236-7672
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202005782224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant