Provider Demographics
NPI:1538216452
Name:PELTON COOPER, MARY M (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:PELTON COOPER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 LONGYEAR DR
Mailing Address - Street 2:
Mailing Address - City:NEGAUNEE
Mailing Address - State:MI
Mailing Address - Zip Code:49866-9601
Mailing Address - Country:US
Mailing Address - Phone:906-226-3004
Mailing Address - Fax:
Practice Address - Street 1:112 W WASHINGTON ST
Practice Address - Street 2:SUITE C
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4348
Practice Address - Country:US
Practice Address - Phone:906-360-3544
Practice Address - Fax:906-225-1781
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010226103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical