Provider Demographics
NPI:1821380221
Name:COOPER, TRAVIS WILLIAM
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:WILLIAM
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1909
Mailing Address - Country:US
Mailing Address - Phone:937-493-0004
Mailing Address - Fax:
Practice Address - Street 1:1717 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-1909
Practice Address - Country:US
Practice Address - Phone:937-493-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP10019235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist