Provider Demographics
NPI:1962928606
Name:COOPER, MALLORY CATHERINE (CTRS)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:CATHERINE
Last Name:COOPER
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 MERCED ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1721
Mailing Address - Country:US
Mailing Address - Phone:559-892-1125
Mailing Address - Fax:
Practice Address - Street 1:2140 MERCED ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1721
Practice Address - Country:US
Practice Address - Phone:559-892-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69061225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist