Provider Demographics
NPI:1407924459
Name:COOPER, MICHELLE LATRICE (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LATRICE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:LATRICE
Other - Last Name:HOOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 290115
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-0002
Mailing Address - Country:US
Mailing Address - Phone:803-928-0369
Mailing Address - Fax:866-524-1024
Practice Address - Street 1:318 BLUESTEM DR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-2103
Practice Address - Country:US
Practice Address - Phone:803-928-0369
Practice Address - Fax:866-524-1024
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3368235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0518Medicaid