Provider Demographics
NPI:1972716959
Name:COPPOCK, RAYMOND (CDCII, BHAII)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:COPPOCK
Suffix:
Gender:M
Credentials:CDCII, BHAII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 256
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 SHORE AVE
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752-9800
Practice Address - Country:US
Practice Address - Phone:907-442-7640
Practice Address - Fax:907-442-7749
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
AK1331101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker