Healthcare Provider Details

I. General information

NPI: 1013175819
Provider Name (Legal Business Name): ANN CHARISE LUCIANO COOPER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 NE 5TH ST
GRESHAM OR
97030-7345
US

IV. Provider business mailing address

18176 MEADOW AVE
SANDY OR
97055-6821
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5600
  • Fax:
Mailing address:
  • Phone: 541-264-0285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1073508
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: