Provider Demographics
NPI:1740598135
Name:COOPER, CATHLEEN MARIE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:MARIE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 LEATHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-9236
Mailing Address - Country:US
Mailing Address - Phone:330-433-1311
Mailing Address - Fax:
Practice Address - Street 1:251 LEATHERMAN RD
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-9236
Practice Address - Country:US
Practice Address - Phone:330-334-6229
Practice Address - Fax:330-334-6110
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6299133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0228242Medicaid
OH6299OtherLICENSE