Provider Demographics
NPI:1194148528
Name:COPELAND, MARY
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
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 1:1801 MICHAEL DR N
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-2095
Mailing Address - Country:US
Mailing Address - Phone:317-313-0903
Mailing Address - Fax:
Practice Address - Street 1:1801 MICHAEL DR N
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2095
Practice Address - Country:US
Practice Address - Phone:317-313-0903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20900240225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist