Provider Demographics
NPI:1295043487
Name:COOPER, MARY JEAN (MA SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:COOPER
Suffix:
Gender:F
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 SAINT LAWRENCE WAY
Mailing Address - Street 2:
Mailing Address - City:FURLONG
Mailing Address - State:PA
Mailing Address - Zip Code:18925-1001
Mailing Address - Country:US
Mailing Address - Phone:718-494-2141
Mailing Address - Fax:
Practice Address - Street 1:515 SAINT LAWRENCE WAY
Practice Address - Street 2:
Practice Address - City:FURLONG
Practice Address - State:PA
Practice Address - Zip Code:18925-1001
Practice Address - Country:US
Practice Address - Phone:718-494-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA013278235Z00000X
NY020376-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist