Provider Demographics
NPI:1801130794
Name:COOPER, BRIAN DAVID (CMT/LMT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:COOPER
Suffix:
Gender:M
Credentials:CMT/LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9272 CALADIUM DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-6083
Mailing Address - Country:US
Mailing Address - Phone:973-800-5194
Mailing Address - Fax:
Practice Address - Street 1:7450 HERITAGE VILLAGE PLZ
Practice Address - Street 2:SUITE 201
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3090
Practice Address - Country:US
Practice Address - Phone:973-800-5194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019009629172M00000X
DCMT1634172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist