Basic Information
| Provider Information | |||||||||
| NPI: | 1790034502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | BLAIZE | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2135 S FREEMONT AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2135 S FREEMONT AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2012 | ||||||||
| LastUpdateDate: | 09/07/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2012017269 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.