Provider Demographics
NPI:1568502532
Name:COOPER, PAULA K (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:K
Last Name:COOPER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:PAULA
Other - Middle Name:K
Other - Last Name:BENHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:345 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1228
Mailing Address - Country:US
Mailing Address - Phone:262-763-9191
Mailing Address - Fax:262-763-7767
Practice Address - Street 1:345 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1228
Practice Address - Country:US
Practice Address - Phone:262-763-9191
Practice Address - Fax:262-763-7767
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
IL1859453103TS0200X
WI867-058103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43598000Medicaid