Provider Demographics
NPI:1508454380
Name:COOPER, TERESA S (CM61087822)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:S
Last Name:COOPER
Suffix:
Gender:F
Credentials:CM61087822
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-2875
Mailing Address - Country:US
Mailing Address - Phone:509-204-3098
Mailing Address - Fax:
Practice Address - Street 1:201 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:BUENA
Practice Address - State:WA
Practice Address - Zip Code:98921-0139
Practice Address - Country:US
Practice Address - Phone:509-865-6705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2470A2800XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationAssistant Record Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA910755984Medicaid