Provider Demographics
NPI:1255347407
Name:COOPER, JOHN K (LICENSEDPSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:COOPER
Suffix:
Gender:M
Credentials:LICENSEDPSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 BRIARFIELD BLVD
Mailing Address - Street 2:STE. 3
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-8919
Mailing Address - Country:US
Mailing Address - Phone:419-866-2830
Mailing Address - Fax:419-866-2831
Practice Address - Street 1:3600 BRIARFIELD BLVD
Practice Address - Street 2:STE. 3
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-8919
Practice Address - Country:US
Practice Address - Phone:419-866-2830
Practice Address - Fax:419-866-2831
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2223103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH271336OtherVALUE OPTIONS