Healthcare Provider Details

I. General information

NPI: 1487303970
Provider Name (Legal Business Name): BREA COOPER BS, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 COIT AVE NE
GRAND RAPIDS MI
49505-4001
US

IV. Provider business mailing address

938 N BOSSETT RD
RAVENNA MI
49451-9545
US

V. Phone/Fax

Practice location:
  • Phone: 616-604-0451
  • Fax:
Mailing address:
  • Phone: 231-286-9616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502001804
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: