Provider Demographics
NPI:1104424597
Name:COOPER, EMILY MARIE (MSOT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9057 PETRIE RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13030-8706
Mailing Address - Country:US
Mailing Address - Phone:315-396-3494
Mailing Address - Fax:
Practice Address - Street 1:23 MEXICO ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316-1203
Practice Address - Country:US
Practice Address - Phone:315-820-8014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024839-01225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist