Provider Demographics
NPI:1013059674
Name:COOPER, AUTUMN MICHELLE (MBS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:MICHELLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MBS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-7044
Mailing Address - Country:US
Mailing Address - Phone:580-223-9705
Mailing Address - Fax:
Practice Address - Street 1:405 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-7044
Practice Address - Country:US
Practice Address - Phone:580-223-9705
Practice Address - Fax:580-223-8736
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3658101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional