MEDICARE: STACEY R. COOPER P.T.

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	225100000X	Physical Therapist	PT00008838	WA

General Provider Information

NPI Number	:	1528000320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY R. COOPER P.T.

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2222
Fax Number	:	630-759-9510

Provider Business Practice Location Address
First Line	:	10004 204TH AVE E
Second Line	:	STE 3100
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-6539
Country	:	US
Telephone Number	:	253-863-7510
Fax Number	:	253-863-5970

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

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	06/25/2015

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