Provider Demographics
NPI:1245746734
Name:COOPER, KEITH ANDRE
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ANDRE
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2185 FALLING STAR LOOP
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-6884
Mailing Address - Country:US
Mailing Address - Phone:510-239-6237
Mailing Address - Fax:
Practice Address - Street 1:2185 FALLING STAR LOOP
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-6884
Practice Address - Country:US
Practice Address - Phone:510-239-6237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst