Provider Demographics
NPI:1982650222
Name:COOPER, ELAINE MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MICHELLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:MICHELLE
Other - Last Name:PETRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8261 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-1133
Mailing Address - Fax:219-365-7703
Practice Address - Street 1:8261 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8878
Practice Address - Country:US
Practice Address - Phone:219-365-1133
Practice Address - Fax:219-365-7703
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002423A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200423350Medicaid
473320SSSMedicare PIN
IN217780RMedicare PIN
IN495210DMedicare PIN