Provider Demographics
NPI:1053147678
Name:COPELAND, MIA (PT, DPT)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:COPELAND
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2694 PGA BLVD
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-8881
Mailing Address - Country:US
Mailing Address - Phone:850-240-5241
Mailing Address - Fax:
Practice Address - Street 1:8418 E BAY BLVD
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-6306
Practice Address - Country:US
Practice Address - Phone:850-348-1899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT41920225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist