Provider Demographics
NPI:1497006290
Name:COOPER, MARLA JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:JEAN
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 S TELSHOR BLVD
Mailing Address - Street 2:#B
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4861
Mailing Address - Country:US
Mailing Address - Phone:575-642-1292
Mailing Address - Fax:
Practice Address - Street 1:3961 E LOHMAN AVE STE 34
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8269
Practice Address - Country:US
Practice Address - Phone:575-525-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5230172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist