Provider Demographics
NPI:1518553148
Name:COOPER, QUALINA J
Entity Type:Individual
Prefix:
First Name:QUALINA
Middle Name:J
Last Name: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 1:12707 BEARS DEN LN # IN
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4463
Mailing Address - Country:US
Mailing Address - Phone:240-801-0600
Mailing Address - Fax:
Practice Address - Street 1:12707 BEARS DEN LN # IN
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-4463
Practice Address - Country:US
Practice Address - Phone:240-801-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT83-2317248Medicaid