Provider Demographics
NPI:1588222590
Name:COOPER, SUSAN GAYLE (OTR/L)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAYLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S MAIN ST UNIT 3166
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-6319
Mailing Address - Country:US
Mailing Address - Phone:208-720-3729
Mailing Address - Fax:
Practice Address - Street 1:1050 FOX ACRES RD
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8456
Practice Address - Country:US
Practice Address - Phone:208-720-3729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-475225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDOT-475OtherSTATE LICENSE