Provider Demographics
NPI:1679734388
Name:COOMER, THERESA (PT)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:COOMER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-0572
Mailing Address - Country:US
Mailing Address - Phone:502-807-4110
Mailing Address - Fax:502-384-4791
Practice Address - Street 1:5751 PRESTON HWY
Practice Address - Street 2:STE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1349
Practice Address - Country:US
Practice Address - Phone:502-807-4110
Practice Address - Fax:502-384-4791
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist