Provider Demographics
NPI:1417659400
Name:COOPER, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
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 1:14508 LIVINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-2806
Mailing Address - Country:US
Mailing Address - Phone:301-613-6982
Mailing Address - Fax:
Practice Address - Street 1:2041 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7024
Practice Address - Country:US
Practice Address - Phone:202-547-8450
Practice Address - Fax:202-610-7147
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management