Provider Demographics
NPI:1174758783
Name:COOPER, BARRY (LMT)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:BARRY
Other - Middle Name:
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:8424 4TH ST N STE G
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3654
Mailing Address - Country:US
Mailing Address - Phone:727-826-4754
Mailing Address - Fax:
Practice Address - Street 1:6000 TURKEY LAKE RD
Practice Address - Street 2:SUITE 208
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-4200
Practice Address - Country:US
Practice Address - Phone:407-468-4023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42528225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid
$$$$$$$$$Medicare UPIN
FL$$$$$$$$$Medicaid