Provider Demographics
NPI:1891144564
Name:COOPER, MADELINE (MED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 EAGLE GROVE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:DEWY ROSE
Mailing Address - State:GA
Mailing Address - Zip Code:30634-1708
Mailing Address - Country:US
Mailing Address - Phone:706-436-4474
Mailing Address - Fax:
Practice Address - Street 1:14701 CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-8712
Practice Address - Country:US
Practice Address - Phone:317-674-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist