MEDICARE: MRS. KATHLEEN A COOPER RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	111564	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34224016	OTHER	MO	BCBSKC

General Provider Information

NPI Number	:	1619910304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN A COOPER RPT

Provider Business Mailing Address
First Line	:	607 S MAIN ST
Second Line	:	SUITE A
City	:	CONCORDIA
State	:	MO
Zip	:	64020-2503
Country	:	US
Telephone Number	:	660-463-7494
Fax Number	:

Provider Business Practice Location Address
First Line	:	PHYSICAL THERAPY OF CONCORDIA
Second Line	:	607 SOUTH MAIN STREET, SUITE A
City	:	CONCORDIA
State	:	MO
Zip	:	64020
Country	:	US
Telephone Number	:	660-463-2588
Fax Number	:	660-463-2589

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	09/30/2013

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