Provider Demographics
NPI:1629559174
Name:COOPER, TYWONDA (COTA)
Entity type:Individual
Prefix:MRS
First Name:TYWONDA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 HYDRANGEA AVE
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-5092
Mailing Address - Country:US
Mailing Address - Phone:254-319-3923
Mailing Address - Fax:
Practice Address - Street 1:2409 HYDRANGEA AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-5092
Practice Address - Country:US
Practice Address - Phone:254-319-3923
Practice Address - Fax:254-699-1547
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210067224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant