Provider Demographics
NPI:1295224681
Name:COOPER, LEANDRA (OT)
Entity Type:Individual
Prefix:
First Name:LEANDRA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8874 CONWHIT LN SW
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9401
Mailing Address - Country:US
Mailing Address - Phone:360-535-3534
Mailing Address - Fax:
Practice Address - Street 1:2051 POTTERY AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2010
Practice Address - Country:US
Practice Address - Phone:360-876-4461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60732310225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA225X00000XMedicaid