Provider Demographics
NPI:1548333446
Name:COOPER, KIPP MARTIN (PT)
Entity type:Individual
Prefix:MR
First Name:KIPP
Middle Name:MARTIN
Last Name:COOPER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 RIDGELAND RD
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-1215
Mailing Address - Country:US
Mailing Address - Phone:607-334-5698
Mailing Address - Fax:607-336-6950
Practice Address - Street 1:26 CONKEY AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1756
Practice Address - Country:US
Practice Address - Phone:607-334-5074
Practice Address - Fax:607-336-6950
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003207225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY438115OtherMVP
NY10034153OtherCD-PHP
0008744OtherGHI
0008744OtherGHI