Provider Demographics
NPI:1225801152
Name:COOPER, MELONIE AMANDA
Entity Type:Individual
Prefix:
First Name:MELONIE
Middle Name:AMANDA
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 1:3613 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4225
Mailing Address - Country:US
Mailing Address - Phone:407-765-5078
Mailing Address - Fax:
Practice Address - Street 1:3613 SCOTT ST
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4225
Practice Address - Country:US
Practice Address - Phone:407-765-5078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLOTA15608224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician