Provider Demographics
NPI:1568005130
Name:COOPER, DEREK KEVIN
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:KEVIN
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 1:14103 BRAMBLE LN APT 201
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-1257
Mailing Address - Country:US
Mailing Address - Phone:240-393-5068
Mailing Address - Fax:443-288-4582
Practice Address - Street 1:5058 DORSEY HALL DR STE 103
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7850
Practice Address - Country:US
Practice Address - Phone:410-884-9200
Practice Address - Fax:443-288-4582
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9653101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health