Healthcare Provider Details

I. General information

NPI: 1730456153
Provider Name (Legal Business Name): NICOLE COPELAND PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 E MAIN ST
MCCONNELSVILLE OH
43756-1180
US

IV. Provider business mailing address

1500 GRAND CENTRAL AVE STE 101
VIENNA WV
26105-1079
US

V. Phone/Fax

Practice location:
  • Phone: 740-962-4441
  • Fax: 740-962-4488
Mailing address:
  • Phone: 304-693-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT013538
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: