Provider Demographics
NPI:1174152813
Name:COPELAND, EBONI BROOKE (OTR/L)
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:BROOKE
Last Name:COPELAND
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 211111
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29221-6111
Mailing Address - Country:US
Mailing Address - Phone:803-466-4017
Mailing Address - Fax:
Practice Address - Street 1:2514 FARAWAY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-3969
Practice Address - Country:US
Practice Address - Phone:803-865-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-05
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNONEOtherNONE