Healthcare Provider Details

I. General information

NPI: 1407575749
Provider Name (Legal Business Name): CARMEN COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 SAINT JOSEPH DR
BLOOMINGTON IL
61701-3638
US

IV. Provider business mailing address

507 E ARMSTRONG AVE
PEORIA IL
61603-3201
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-8275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: