Provider Demographics
NPI:1063796480
Name:COOPER, MEGAN LAURA (PT, DPT)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LAURA
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 1:1423 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5351
Mailing Address - Country:US
Mailing Address - Phone:269-323-4300
Mailing Address - Fax:
Practice Address - Street 1:1423 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5351
Practice Address - Country:US
Practice Address - Phone:269-323-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI550105684225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist