Basic Information
| Provider Information | |||||||||
| NPI: | 1972716959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPPOCK | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CDCII, BHAII | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 256 | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520256 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 SHORE AVE | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997529800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427640 | ||||||||
| FaxNumber: | 9074427749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | AK | N | Other Service Providers | Community Health Worker | 101YA0400X | 1331 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.