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General NPI Number Information
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NPI Number | 1487303970
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Entity Type | Individual
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Provider Name | BREA COOPER BS, PTA
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Gender | Female
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Dates
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Enumeration Date | 03/22/2022
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Last Update Date | 03/22/2022
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Provider Practice Location Address
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Address Line | 2420 COIT AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-4001
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Country | US
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Telephone | 616-604-0451
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Fax |
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Provider Business Mailing Address
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Address Line | 938 N BOSSETT RD
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City | RAVENNA
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State | MI
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Zip | 49451-9545
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Country | US
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Telephone | 231-286-9616
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 5502001804
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License Number State | MI
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