Provider Demographics
NPI:1841044591
Name:COPPER, RAVEN TIFFANY
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:TIFFANY
Last Name:COPPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:TIFFANY
Other - Last Name:SADDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:73 BUNKER HILL AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2221
Mailing Address - Country:US
Mailing Address - Phone:203-706-2260
Mailing Address - Fax:
Practice Address - Street 1:73 BUNKER HILL AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2221
Practice Address - Country:US
Practice Address - Phone:203-706-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7227101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional