Provider Demographics
NPI:1457630196
Name:COOPER, RENEE MICHELE (MP)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:MICHELE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25027 SE 200TH ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-8800
Mailing Address - Country:US
Mailing Address - Phone:425-432-0845
Mailing Address - Fax:
Practice Address - Street 1:670 NW GILMAN BLVD
Practice Address - Street 2:SUITE B2
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2444
Practice Address - Country:US
Practice Address - Phone:425-427-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60232260225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist