Provider Demographics
NPI:1053573782
Name:COOPER, JOHN LOGAN (DPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LOGAN
Last Name:COOPER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5024 DORSEY HALL DR
Mailing Address - Street 2:STE 103
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7869
Mailing Address - Country:US
Mailing Address - Phone:410-740-1047
Mailing Address - Fax:410-740-2280
Practice Address - Street 1:5024 DORSEY HALL DR
Practice Address - Street 2:STE 103
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7869
Practice Address - Country:US
Practice Address - Phone:410-740-1047
Practice Address - Fax:410-740-2280
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist