Provider Demographics
NPI:1821512872
Name:COOPER, ILANA LINDSAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ILANA
Middle Name:LINDSAY
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 1:1419 BEACON ST STE 36
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-4808
Mailing Address - Country:US
Mailing Address - Phone:857-400-8696
Mailing Address - Fax:
Practice Address - Street 1:1419 BEACON ST STE 36
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4808
Practice Address - Country:US
Practice Address - Phone:857-400-8696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10649103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10649OtherBOARD OF REGISTRATION OF PSYCHOLOGISTS