Provider Demographics
NPI:1164066064
Name:COOPER, GRAHAM ELLIOT ROME (PHD)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:ELLIOT ROME
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 1:3554 ROUND BARN BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0929
Mailing Address - Country:US
Mailing Address - Phone:707-571-3778
Mailing Address - Fax:
Practice Address - Street 1:3554 ROUND BARN BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-0929
Practice Address - Country:US
Practice Address - Phone:707-571-3778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60923579103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPY60923579OtherPSYCHOLOGIST LICENSE
CA32078OtherPSYCHOLOGIST LICENSE