Provider Demographics
NPI:1164022661
Name:COOPER, GERRON (BCBA)
Entity Type:Individual
Prefix:
First Name:GERRON
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 ANDERSON RD APT 1306
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-1633
Mailing Address - Country:US
Mailing Address - Phone:703-541-8080
Mailing Address - Fax:
Practice Address - Street 1:3814 12TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2630
Practice Address - Country:US
Practice Address - Phone:202-469-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001793103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty