Provider Demographics
NPI:1518397157
Name:COOPER, CALLISA (PT, DPT)
Entity type:Individual
Prefix:MISS
First Name:CALLISA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 MARSHALL RD APT 2
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-5756
Mailing Address - Country:US
Mailing Address - Phone:443-756-1210
Mailing Address - Fax:
Practice Address - Street 1:4300 SONOMA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2200
Practice Address - Country:US
Practice Address - Phone:707-645-2720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT41487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist