Provider Demographics
NPI:1134308752
Name:COOPER, GRETCHEN LEANNE (PT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:LEANNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 N CHARLOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-2003
Mailing Address - Country:US
Mailing Address - Phone:254-965-8964
Mailing Address - Fax:
Practice Address - Street 1:955 N CHARLOTTE AVE
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-2003
Practice Address - Country:US
Practice Address - Phone:254-965-8964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1073765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T5471OtherBLUE CROSS BLUE SHIELD
TX063257202Medicaid
TX063257201Medicaid