Provider Demographics
NPI:1265763098
Name:COOPER, KELLY MARIE (LMBT)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:MARIE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FAIRVIEW HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NC
Mailing Address - Zip Code:28730-9777
Mailing Address - Country:US
Mailing Address - Phone:828-777-5083
Mailing Address - Fax:
Practice Address - Street 1:25 QUAIL HOLLOW RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:NC
Practice Address - Zip Code:28730-8505
Practice Address - Country:US
Practice Address - Phone:828-777-5083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5397225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist