Provider Demographics
NPI:1609628577
Name:COOPER, SHAUNTAE T (MASTER COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:SHAUNTAE
Middle Name:T
Last Name:COOPER
Suffix:
Gender:F
Credentials:MASTER COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W 40TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31415-8707
Mailing Address - Country:US
Mailing Address - Phone:912-604-1172
Mailing Address - Fax:
Practice Address - Street 1:218 W VICTORY DR STE 9
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-1718
Practice Address - Country:US
Practice Address - Phone:912-231-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO126617174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist