Provider Demographics
NPI:1073037529
Name:COOPER, ROBERT SHANE (COTA/L)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SHANE
Last Name:COOPER
Suffix:
Gender:M
Credentials:COTA/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 271
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:VA
Mailing Address - Zip Code:24165-0271
Mailing Address - Country:US
Mailing Address - Phone:276-340-7132
Mailing Address - Fax:
Practice Address - Street 1:300 BLUE RIDGE ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-7261
Practice Address - Country:US
Practice Address - Phone:276-340-7132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000278224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant