Provider Demographics
NPI:1891771887
Name:COOPER, GLEN LAWRENCE (ATC)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:LAWRENCE
Last Name:COOPER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 STONEYCREEK LN
Mailing Address - Street 2:
Mailing Address - City:HARRISON CITY
Mailing Address - State:PA
Mailing Address - Zip Code:15636-1308
Mailing Address - Country:US
Mailing Address - Phone:724-744-4974
Mailing Address - Fax:
Practice Address - Street 1:BOX 530, ROUTE 130
Practice Address - Street 2:
Practice Address - City:HARRISON CITY
Practice Address - State:PA
Practice Address - Zip Code:15636
Practice Address - Country:US
Practice Address - Phone:724-744-4471
Practice Address - Fax:724-744-1214
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART000248A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist