Provider Demographics
NPI:1548803679
Name:COOPER, CODY WILLIAM (AT, ATC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:WILLIAM
Last Name:COOPER
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 VINEWOOD ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1269
Mailing Address - Country:US
Mailing Address - Phone:989-240-0789
Mailing Address - Fax:
Practice Address - Street 1:1200 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-2001
Practice Address - Country:US
Practice Address - Phone:989-774-1663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010022132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer