Provider Demographics
NPI:1508418211
Name:COOPER, BRENDA SUE (CDCA 168347)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:SUE
Last Name:COOPER
Suffix:
Gender:F
Credentials:CDCA 168347
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-4956
Mailing Address - Country:US
Mailing Address - Phone:740-244-7680
Mailing Address - Fax:
Practice Address - Street 1:546 PEARL ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-4956
Practice Address - Country:US
Practice Address - Phone:740-244-7680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168347101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional