Provider Demographics
NPI:1568900959
Name:COOPER, GERALD
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
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 1:11331 EMBASSY DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-3009
Mailing Address - Country:US
Mailing Address - Phone:513-763-9474
Mailing Address - Fax:
Practice Address - Street 1:199 WILLIAM HOWARD TAFT RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2103
Practice Address - Country:US
Practice Address - Phone:513-616-8774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.130650101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)