Provider Demographics
NPI:1477285039
Name:GILL-COOPER, AYANNA ETTANN
Entity Type:Individual
Prefix:
First Name:AYANNA
Middle Name:ETTANN
Last Name:GILL-COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15239 WINDMILL RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-8805
Mailing Address - Country:US
Mailing Address - Phone:601-955-0610
Mailing Address - Fax:
Practice Address - Street 1:15239 WINDMILL RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-8805
Practice Address - Country:US
Practice Address - Phone:601-955-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1778101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health