MEDICARE: COPE PERSONAL DEVELOPMENT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	6401003666	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679083372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COPE PERSONAL DEVELOPMENT CENTER

Provider Business Mailing Address
First Line	:	30016 HANOVER BLVD
Second Line	:
City	:	WESTLAND
State	:	MI
Zip	:	48186-5125
Country	:	US
Telephone Number	:	248-991-5779
Fax Number	:	888-318-6010

Provider Business Practice Location Address
First Line	:	26711 WOODWARD AVE STE LL2
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1370
Country	:	US
Telephone Number	:	855-948-1661
Fax Number	:	888-318-6010

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TINA LARAYNE PARKMAN
Credential	:	PH.D
Telephone Number	:	248-991-5779

Provider Enumeration Date	:	10/07/2017
Last Update Date	:	10/09/2018

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