Provider Demographics
NPI:1154674109
Name:COOPER, THOMAS M (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
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 1:251 WOODFORD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5617
Mailing Address - Country:US
Mailing Address - Phone:207-773-2828
Mailing Address - Fax:207-761-8150
Practice Address - Street 1:251 WOODFORD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5617
Practice Address - Country:US
Practice Address - Phone:207-253-9435
Practice Address - Fax:888-765-8406
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1363103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical