Healthcare Provider Details

I. General information

NPI: 1437578622
Provider Name (Legal Business Name): RAPHAEL COPELAND PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 E 93RD ST
CHICAGO IL
60617-3909
US

IV. Provider business mailing address

2320 E 93RD ST
CHICAGO IL
60617-3909
US

V. Phone/Fax

Practice location:
  • Phone: 773-967-5221
  • Fax: 708-938-5239
Mailing address:
  • Phone: 773-967-5221
  • Fax: 708-938-5239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160006704
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: