Provider Demographics
NPI:1588154629
Name:COOPER, CODY (RBT)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 DEER PATH RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1110
Mailing Address - Country:US
Mailing Address - Phone:815-319-8867
Mailing Address - Fax:
Practice Address - Street 1:3433 DEER PATH RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1110
Practice Address - Country:US
Practice Address - Phone:815-319-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-37310106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician