Basic Information
| Provider Information | |||||||||
| NPI: | 1356869028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOLEY | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | ANNETTE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8259 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463738878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656560 | ||||||||
| FaxNumber: | 2193656561 | ||||||||
| Practice Location | |||||||||
| Address1: | 3170 WILLOWCREEK RD | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463684424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192863890 | ||||||||
| FaxNumber: | 2192863891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2017 | ||||||||
| LastUpdateDate: | 09/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.