Provider Demographics
NPI:1144065368
Name:COOPER, ROSA
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 RED SUNSET DRIVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-4481
Mailing Address - Country:US
Mailing Address - Phone:256-566-7170
Mailing Address - Fax:
Practice Address - Street 1:1508 15TH AVENUE SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-5404
Practice Address - Country:US
Practice Address - Phone:256-566-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL385H00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care