MEDICARE: DR. TERRY FRED COPELAND PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	600 559 777	WA
2	103TC1900X	Counseling Psychologist	PY00000801	WA

General Provider Information

NPI Number	:	1578587432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY FRED COPELAND PHD

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

Provider Business Practice Location Address
First Line	:	6912 220TH ST SW
Second Line	:	SUITE 113
City	:	MOUNTLAKE TERRACE
State	:	WA
Zip	:	98043-2169
Country	:	US
Telephone Number	:	425-361-7670
Fax Number	:	425-967-5572

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	03/06/2018

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