Provider Demographics
NPI:1649307133
Name:COOSEMAN, MATTHEW LARRY
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LARRY
Last Name:COOSEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 WATERFORD DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-3649
Mailing Address - Country:US
Mailing Address - Phone:314-521-6060
Mailing Address - Fax:314-524-9854
Practice Address - Street 1:8390 LATTY AVE
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-3236
Practice Address - Country:US
Practice Address - Phone:314-521-6060
Practice Address - Fax:314-524-9854
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)