Provider Demographics
NPI:1649529330
Name:COOPER, KRISTEN
Entity type:Individual
Prefix:
First Name:KRISTEN
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 1:1079 E MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-5901
Mailing Address - Country:US
Mailing Address - Phone:423-318-7373
Mailing Address - Fax:423-318-7474
Practice Address - Street 1:1079 E MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-5901
Practice Address - Country:US
Practice Address - Phone:423-318-7373
Practice Address - Fax:423-318-7474
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000003822101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029407Medicaid