Provider Demographics
NPI:1104837996
Name:COOPER, STEWART E (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEWART
Middle Name:E
Last Name:COOPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 LEGEND DR
Mailing Address - Street 2:APARTMENT 203
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-6696
Mailing Address - Country:US
Mailing Address - Phone:219-464-0311
Mailing Address - Fax:
Practice Address - Street 1:826 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4534
Practice Address - Country:US
Practice Address - Phone:219-464-5002
Practice Address - Fax:219-464-6865
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040467103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN659800Medicare ID - Type Unspecified