Provider Demographics
NPI:1497827380
Name:COOPER-NICOLS, MARJORIE BARBARA (PHD)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:BARBARA
Last Name:COOPER-NICOLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-3907
Mailing Address - Country:US
Mailing Address - Phone:631-243-5835
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4231
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019594-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical