Provider Demographics
NPI:1780891796
Name:COOPER, MARY ELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:COOPER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:LA VETA
Mailing Address - State:CO
Mailing Address - Zip Code:81055-0068
Mailing Address - Country:US
Mailing Address - Phone:719-742-3704
Mailing Address - Fax:719-742-3704
Practice Address - Street 1:115 W. RYUS AVE.
Practice Address - Street 2:
Practice Address - City:LA VETA
Practice Address - State:CO
Practice Address - Zip Code:81055
Practice Address - Country:US
Practice Address - Phone:719-742-3704
Practice Address - Fax:719-742-3704
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO121106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist