Provider Demographics
NPI:1659815017
Name:COOPER, CAROLYN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-6001
Mailing Address - Country:US
Mailing Address - Phone:239-334-1091
Mailing Address - Fax:
Practice Address - Street 1:2826 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-6001
Practice Address - Country:US
Practice Address - Phone:239-334-1091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA7655224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant