Healthcare Provider Details

I. General information

NPI: 1972716959
Provider Name (Legal Business Name): RAYMOND COPPOCK CDCII, BHAII
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SHORE AVE
KOTZEBUE AK
99752-9800
US

IV. Provider business mailing address

PO BOX 256
KOTZEBUE AK
99752-0256
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-7640
  • Fax: 907-442-7749
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1331
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: