Provider Demographics
NPI:1922193820
Name:COPELAND, CHRISTINA G
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:G
Last Name:COPELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 N SACRAMENTO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3517
Mailing Address - Country:US
Mailing Address - Phone:312-413-1563
Mailing Address - Fax:312-413-1993
Practice Address - Street 1:1640 W ROOSEVELT RD
Practice Address - Street 2:ROOM 336 (M/C 628)
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1316
Practice Address - Country:US
Practice Address - Phone:312-413-1563
Practice Address - Fax:312-413-1993
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical