Healthcare Provider Details

I. General information

NPI: 1083981559
Provider Name (Legal Business Name): ELIZABETH COOPER PORTER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 TRADITIONS AVE
BOWLING GREEN KY
42103
US

IV. Provider business mailing address

210 AUGUSTA AVE
BOWLING GREEN KY
42103-2537
US

V. Phone/Fax

Practice location:
  • Phone: 606-303-8634
  • Fax: 317-520-8200
Mailing address:
  • Phone: 606-303-8634
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberRO183
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number132707
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: