Provider Demographics
NPI:1164649455
Name:COOPER, REGINA C (SLP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:C
Last Name:COOPER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 SEVEN BAR LOOP RD NW
Mailing Address - Street 2:SEVEN BAR ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5600
Mailing Address - Country:US
Mailing Address - Phone:505-899-2797
Mailing Address - Fax:
Practice Address - Street 1:4501 SEVEN BAR LOOP RD NW
Practice Address - Street 2:SEVEN BAR ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5600
Practice Address - Country:US
Practice Address - Phone:505-899-2797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1355235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML 0294Medicaid