Provider Demographics
NPI:1396505905
Name:COOPER, MITCHELL DEAN
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DEAN
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14120 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-3319
Mailing Address - Country:US
Mailing Address - Phone:952-715-2125
Mailing Address - Fax:
Practice Address - Street 1:860 BLUE GENTIAN RD STE 200
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1567
Practice Address - Country:US
Practice Address - Phone:651-802-2533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst