Provider Demographics
NPI:1134169154
Name:COOPER, ANTIONETTE T (PSYD)
Entity type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:T
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 1:1790 TOWN PARK BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-7972
Mailing Address - Country:US
Mailing Address - Phone:330-753-1734
Mailing Address - Fax:
Practice Address - Street 1:1790 TOWN PARK BLVD
Practice Address - Street 2:STE C
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-7972
Practice Address - Country:US
Practice Address - Phone:330-753-1734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5307103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP22684Medicare ID - Type Unspecified