Provider Demographics
NPI:1700961562
Name:COOPER, KEVIN KELLER (OT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:KELLER
Last Name:COOPER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 85
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:NY
Mailing Address - Zip Code:12936
Mailing Address - Country:US
Mailing Address - Phone:518-963-8051
Mailing Address - Fax:
Practice Address - Street 1:2736 RTE 22
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:NY
Practice Address - Zip Code:12936
Practice Address - Country:US
Practice Address - Phone:518-963-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0132401225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist