Provider Demographics
NPI:1487303970
Name:COOPER, BREA (BS, PTA)
Entity type:Individual
Prefix:
First Name:BREA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:BS, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 N BOSSETT RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-9545
Mailing Address - Country:US
Mailing Address - Phone:231-286-9616
Mailing Address - Fax:
Practice Address - Street 1:2420 COIT AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4001
Practice Address - Country:US
Practice Address - Phone:616-604-0451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001804225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant