Provider Demographics
NPI:1962453449
Name:COOPER, AMY DIANE (MA)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:DIANE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MAIN ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5216
Mailing Address - Country:US
Mailing Address - Phone:802-651-7526
Mailing Address - Fax:802-862-9158
Practice Address - Street 1:3 MAIN ST
Practice Address - Street 2:SUITE 107
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5216
Practice Address - Country:US
Practice Address - Phone:802-651-7526
Practice Address - Fax:802-862-9158
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000635101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT105384Medicaid