Provider Demographics
NPI:1598747032
Name:COOPER, KIMBERLY JOY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:JOY
Last Name:COOPER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WHITING HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1006
Mailing Address - Country:US
Mailing Address - Phone:207-973-5035
Mailing Address - Fax:207-973-5042
Practice Address - Street 1:895 UNION ST
Practice Address - Street 2:SUITE 12
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3053
Practice Address - Country:US
Practice Address - Phone:207-973-7979
Practice Address - Fax:207-947-9579
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC046GTOtherBCBS
NC2492750Medicare ID - Type UnspecifiedCIGNA MEDICARE PROVIDER #
NC6000472Medicaid