Provider Demographics
NPI:1861700155
Name:COOPER, BAKEISHA PAYTON
Entity type:Individual
Prefix:MRS
First Name:BAKEISHA
Middle Name:PAYTON
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:PO BOX 7293
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33807-7293
Mailing Address - Country:US
Mailing Address - Phone:863-899-8004
Mailing Address - Fax:866-728-9641
Practice Address - Street 1:590 ROB ROY DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2463
Practice Address - Country:US
Practice Address - Phone:863-899-8004
Practice Address - Fax:866-728-9641
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL689116198171M00000X
FL689116196171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator