Provider Demographics
NPI:1104137413
Name:COOPER, KIMBERLY PAGE (SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PAGE
Last Name:COOPER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 GA HIGHWAY 56 S STE A
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-5328
Mailing Address - Country:US
Mailing Address - Phone:478-237-6363
Mailing Address - Fax:478-237-6364
Practice Address - Street 1:1007 GA HIGHWAY 56 S STE A
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-5328
Practice Address - Country:US
Practice Address - Phone:478-237-6363
Practice Address - Fax:478-237-6364
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA277041361BMedicaid
GASLP007349OtherGA LICENSE