Provider Demographics
NPI:1023068947
Name:COOPER, TABITHA DAWN (OTR/L)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:DAWN
Last Name:COOPER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 SIGEL TRL
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-9441
Mailing Address - Country:US
Mailing Address - Phone:479-659-1857
Mailing Address - Fax:479-621-8506
Practice Address - Street 1:1601 GREENHOUSE RD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72713-9292
Practice Address - Country:US
Practice Address - Phone:479-795-1260
Practice Address - Fax:479-795-1261
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1455OTR225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137338721Medicaid
AR5U652OtherBLUE CROSS BLUE SHIELD