Provider Demographics
NPI:1962867481
Name:COOPER, BREANA (SLP)
Entity Type:Individual
Prefix:
First Name:BREANA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:BREANA
Other - Middle Name:
Other - Last Name:WILLOUGHBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5507 SW 9TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106
Mailing Address - Country:US
Mailing Address - Phone:806-468-7611
Mailing Address - Fax:806-468-7603
Practice Address - Street 1:5507 SW 9TH AVENUE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106
Practice Address - Country:US
Practice Address - Phone:806-468-7611
Practice Address - Fax:806-468-7603
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist