Healthcare Provider Details

I. General information

NPI: 1265763098
Provider Name (Legal Business Name): KELLY MARIE COOPER L.M.B.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 QUAIL HOLLOW RD
FAIRVIEW NC
28730-8505
US

IV. Provider business mailing address

2 FAIRVIEW HILLS DR
FAIRVIEW NC
28730-9777
US

V. Phone/Fax

Practice location:
  • Phone: 828-777-5083
  • Fax:
Mailing address:
  • Phone: 828-777-5083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5397
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: