Healthcare Provider Details

I. General information

NPI: 1346889078
Provider Name (Legal Business Name): MARISA ERIN COPELAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2019
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 COFFEE RD
MODESTO CA
95355-4204
US

IV. Provider business mailing address

1000 COFFEE RD
MODESTO CA
95355-4204
US

V. Phone/Fax

Practice location:
  • Phone: 209-360-7837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: