Healthcare Provider Details

I. General information

NPI: 1710798962
Provider Name (Legal Business Name): KENDRA MICHELLE COOPER BHP, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N 27TH AVE
PHOENIX AZ
85009-4420
US

IV. Provider business mailing address

7212 W LEWIS AVE
PHOENIX AZ
85035-1342
US

V. Phone/Fax

Practice location:
  • Phone: 602-258-6797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-21062
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: