Provider Demographics
NPI:1316364227
Name:COOPER, GENEICE (COTA)
Entity Type:Individual
Prefix:
First Name:GENEICE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S ROWLAND ST
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-1350
Mailing Address - Country:US
Mailing Address - Phone:269-635-8512
Mailing Address - Fax:
Practice Address - Street 1:221 S ROWLAND ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-1350
Practice Address - Country:US
Practice Address - Phone:269-635-8512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202006918171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor