Provider Demographics
NPI:1841624640
Name:COOPER, CALLIE J (PHD)
Entity type:Individual
Prefix:DR
First Name:CALLIE
Middle Name:J
Last Name:COOPER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CALLIE
Other - Middle Name:J
Other - Last Name:BROCKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:331 SIJAN AVE BLDG 2032
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1269
Mailing Address - Country:US
Mailing Address - Phone:660-687-4341
Mailing Address - Fax:
Practice Address - Street 1:331 SIJAN AVE, BLDG 2032
Practice Address - Street 2:
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
LA1355103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist