MEDICARE: KELLI COOPER OTR/L, PTA

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	225200000X	Physical Therapy Assistant
2	225X00000X	Occupational Therapist	OTH-006878	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OTH-006878	OTHER	AZ	LICENSE#
2	7773A	OTHER	AZ	LICENSE#

General Provider Information

NPI Number	:	1639361124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI COOPER OTR/L, PTA

Provider Business Mailing Address
First Line	:	1438 E ANGELINE AVE
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85140-4063
Country	:	US
Telephone Number	:	480-703-6430
Fax Number	:

Provider Business Practice Location Address
First Line	:	2225 W SOUTHERN AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-4716
Country	:	US
Telephone Number	:	480-412-4101
Fax Number	:

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

Provider Enumeration Date	:	08/17/2007
Last Update Date	:	11/06/2018

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