Provider Demographics
NPI:1528831609
Name:COOPER, AMANDA JOY (BS, LAT,ATC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOY
Last Name:COOPER
Suffix:
Gender:F
Credentials:BS, LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 CHRISTINE AVE APT 26
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-4313
Mailing Address - Country:US
Mailing Address - Phone:484-896-8608
Mailing Address - Fax:
Practice Address - Street 1:1036 MEDARY AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57007-0001
Practice Address - Country:US
Practice Address - Phone:605-688-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD07792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer