Basic Information
| Provider Information | |||||||||
| NPI: | 1437578622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPELAND | ||||||||
| FirstName: | RAPHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10233 W ROOSEVELT RD | ||||||||
| Address2: | |||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601542518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089385238 | ||||||||
| FaxNumber: | 7089385239 | ||||||||
| Practice Location | |||||||||
| Address1: | 10001 DERBY LN | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601543749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086812991 | ||||||||
| FaxNumber: | 7089385239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 04/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 160006704 | IL | Y | Other Service Providers | Specialist |
No ID Information.