Healthcare Provider Details

I. General information

NPI: 1316943616
Provider Name (Legal Business Name): ELIZABETH COENEN COOPER M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17028 LEJEUNE ROAD
QUANTICO VA
22134-1757
US

IV. Provider business mailing address

335 BAHIA LN
CAPE CARTERET NC
28584-9356
US

V. Phone/Fax

Practice location:
  • Phone: 703-217-3511
  • Fax: 703-221-6905
Mailing address:
  • Phone: 703-217-3511
  • Fax: 252-764-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202004656
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: