Provider Demographics
NPI:1578228342
Name:COOPER, COLLIN MICHAEL
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:MICHAEL
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 BLUEBIRD WAY
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TX
Mailing Address - Zip Code:75009-1620
Mailing Address - Country:US
Mailing Address - Phone:310-753-1007
Mailing Address - Fax:
Practice Address - Street 1:1132 BLUEBIRD WAY
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TX
Practice Address - Zip Code:75009-1620
Practice Address - Country:US
Practice Address - Phone:310-753-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122060225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist