Provider Demographics
NPI:1417180167
Name:COOPER, ROLLEN MICHAEL (MS)
Entity Type:Individual
Prefix:MR
First Name:ROLLEN
Middle Name:MICHAEL
Last Name:COOPER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 W BELMONT AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6845
Mailing Address - Country:US
Mailing Address - Phone:773-965-1361
Mailing Address - Fax:
Practice Address - Street 1:180 HANSEN CT
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1121
Practice Address - Country:US
Practice Address - Phone:630-595-8200
Practice Address - Fax:630-595-3066
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1910812222Q00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist