Provider Demographics
NPI:1033800701
Name:COOPER, MALLORY CHRISTINE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:CHRISTINE
Last Name:COOPER
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 1:905 1/2 N RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2938
Mailing Address - Country:US
Mailing Address - Phone:217-620-2950
Mailing Address - Fax:
Practice Address - Street 1:589 MINOT AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-4032
Practice Address - Country:US
Practice Address - Phone:207-443-3341
Practice Address - Fax:207-777-1205
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
MESP3893235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist