Provider Demographics
NPI:1477215457
Name:COOPER, TINA WYNN
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:WYNN
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 REXFORD DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-9477
Mailing Address - Country:US
Mailing Address - Phone:864-580-1327
Mailing Address - Fax:
Practice Address - Street 1:243 REXFORD DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:SC
Practice Address - Zip Code:29369-9477
Practice Address - Country:US
Practice Address - Phone:864-580-1327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency