Provider Demographics
NPI:1609766161
Name:COOPER, MARIAH BRADLEY (LMT)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:BRADLEY
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 W ALTORFER DR STE A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1867
Mailing Address - Country:US
Mailing Address - Phone:309-678-7217
Mailing Address - Fax:
Practice Address - Street 1:2627 W ALTORFER DR STE A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1867
Practice Address - Country:US
Practice Address - Phone:309-693-8448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist