Provider Demographics
NPI:1932128295
Name:COOPER, SHAWN (PHD, MPH)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:PHD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 COLE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4853
Mailing Address - Country:US
Mailing Address - Phone:401-861-6237
Mailing Address - Fax:
Practice Address - Street 1:534 ANGELL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4414
Practice Address - Country:US
Practice Address - Phone:401-331-9507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00005103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist