Provider Demographics
NPI:1215150768
Name:COOPER, RENEA JOHNSON (LPTA)
Entity type:Individual
Prefix:
First Name:RENEA
Middle Name:JOHNSON
Last Name:COOPER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 THISTLE RD
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-4558
Mailing Address - Country:US
Mailing Address - Phone:434-332-4998
Mailing Address - Fax:
Practice Address - Street 1:1220 W GRETNA RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:VA
Practice Address - Zip Code:24557-4087
Practice Address - Country:US
Practice Address - Phone:434-656-8535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001592225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant