Provider Demographics
NPI:1174721047
Name:COOPER, KIMBERLY GARRETT (RPT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:GARRETT
Last Name:COOPER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 RIVERBEND CV
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8647
Mailing Address - Country:US
Mailing Address - Phone:601-825-9501
Mailing Address - Fax:
Practice Address - Street 1:112 RIVERBEND CV
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8647
Practice Address - Country:US
Practice Address - Phone:601-825-9501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT01962251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124121Medicaid