Provider Demographics
NPI:1114561081
Name:COOPER, MICHELLE STACEY
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:STACEY
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 1:7 HILLDALE LN
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1208
Mailing Address - Country:US
Mailing Address - Phone:305-494-8150
Mailing Address - Fax:
Practice Address - Street 1:15050 14TH RD
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2609
Practice Address - Country:US
Practice Address - Phone:718-767-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026494-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist