MEDICARE: LAURA LEIGH COOPER DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251G0304X	Geriatric Physical Therapist	26763	MD

General Provider Information

NPI Number	:	1013420884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA LEIGH COOPER DPT

Provider Business Mailing Address
First Line	:	113 COVERED BRIDGE LN
Second Line	:
City	:	FRUITLAND
State	:	MD
Zip	:	21826-1101
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9707 OLD GEORGETOWN RD
Second Line	:
City	:	BETHESDA
State	:	MD
Zip	:	20814-1745
Country	:	US
Telephone Number	:	301-530-0500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2017
Last Update Date	:	11/14/2017

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