Provider Demographics
NPI:1699405837
Name:COOPER, DESTINEE MONET' (LMT)
Entity Type:Individual
Prefix:
First Name:DESTINEE
Middle Name:MONET'
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-3610
Mailing Address - Country:US
Mailing Address - Phone:224-733-5066
Mailing Address - Fax:
Practice Address - Street 1:310 S GREENLEAF ST STE 208
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5708
Practice Address - Country:US
Practice Address - Phone:847-623-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-11
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227021315225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist