Provider Demographics
NPI:1609167907
Name:COOPER, SHAUN (PHD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 725098
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-5098
Mailing Address - Country:US
Mailing Address - Phone:313-587-3092
Mailing Address - Fax:
Practice Address - Street 1:12501 HAMILTON
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203
Practice Address - Country:US
Practice Address - Phone:313-587-3092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008358103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2604097Medicaid
OH2604097Medicaid