Provider Demographics
NPI:1114254265
Name:COOPER, MARITA A (MFTI)
Entity Type:Individual
Prefix:
First Name:MARITA
Middle Name:A
Last Name:COOPER
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 ADELINE STREET
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536
Mailing Address - Country:US
Mailing Address - Phone:510-601-0203
Mailing Address - Fax:510-601-4002
Practice Address - Street 1:3200 ADELINE STREET
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536
Practice Address - Country:US
Practice Address - Phone:510-601-0203
Practice Address - Fax:510-601-4002
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 55449106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist