Provider Demographics
NPI:1952940520
Name:COOPER, TIMOTHY ALLEN (PSYD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:COOPER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:TIMOTHY
Other - Middle Name:ALLEN
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:3331 SW HAMILTON CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-1256
Mailing Address - Country:US
Mailing Address - Phone:503-313-9773
Mailing Address - Fax:
Practice Address - Street 1:3331 SW HAMILTON CT
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-1256
Practice Address - Country:US
Practice Address - Phone:503-313-9773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30767103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical