Healthcare Provider Details

I. General information

NPI: 1578768511
Provider Name (Legal Business Name): JOAN COPELAND OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S 6TH ST
PACIFIC MO
63069-1328
US

IV. Provider business mailing address

7295 HIGHWAY HH
CATAWISSA MO
63015-1296
US

V. Phone/Fax

Practice location:
  • Phone: 636-271-4222
  • Fax:
Mailing address:
  • Phone: 636-257-6503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2000146274
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: