Provider Demographics
NPI:1710256219
Name:COOPER, THERESE JENNIE (SPEECH THERAPY)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:JENNIE
Last Name:COOPER
Suffix:
Gender:F
Credentials:SPEECH THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 AVENIDA ENCINAS
Mailing Address - Street 2:SUITE# 250
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-4381
Mailing Address - Country:US
Mailing Address - Phone:760-729-5433
Mailing Address - Fax:760-621-5680
Practice Address - Street 1:5050 AVENIDA ENCINAS
Practice Address - Street 2:SUITE# 250
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-4381
Practice Address - Country:US
Practice Address - Phone:760-729-5433
Practice Address - Fax:760-621-5680
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASLP 7259235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist