Provider Demographics
NPI:1265514160
Name:COOPER, CYNTHIA
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 UNION ST
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1983
Mailing Address - Country:US
Mailing Address - Phone:248-318-5178
Mailing Address - Fax:
Practice Address - Street 1:317 UNION ST
Practice Address - Street 2:SUITE C-2
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1983
Practice Address - Country:US
Practice Address - Phone:248-318-5178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011735103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF32914OtherBCBS PROVIDER ID