1578587432 NPI number — DR. TERRY FRED COPELAND PHD

Table of content: DR. TERRY FRED COPELAND PHD (NPI 1578587432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578587432 NPI number — DR. TERRY FRED COPELAND PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COPELAND
Provider First Name:
TERRY
Provider Middle Name:
FRED
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578587432
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1020 5TH AVE S
Provider Second Line Business Mailing Address:
APT 10
Provider Business Mailing Address City Name:
EDMONDS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98020-4039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-361-7670
Provider Business Mailing Address Fax Number:
425-967-5572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6912 220TH ST SW
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
MOUNTLAKE TERRACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98043-2169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-361-7670
Provider Business Practice Location Address Fax Number:
425-967-5572
Provider Enumeration Date:
07/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  600 559 777 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: PY00000801 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)