Provider Demographics
NPI:1225440795
Name:COOPER, SHAUN THOMAS (LMT)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:THOMAS
Last Name:COOPER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 HILTON DR
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-5254
Mailing Address - Country:US
Mailing Address - Phone:541-281-9530
Mailing Address - Fax:
Practice Address - Street 1:1235 HILTON DR
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-5254
Practice Address - Country:US
Practice Address - Phone:541-281-9530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5485225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5485OtherLMT NUMBER