Provider Demographics
NPI:1619794419
Name:COOPER, ELIZABETH ANN (BA, CT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:COOPER
Suffix:
Gender:F
Credentials:BA, CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 BANK ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-1025
Mailing Address - Country:US
Mailing Address - Phone:330-350-6234
Mailing Address - Fax:
Practice Address - Street 1:737 BANK ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-1025
Practice Address - Country:US
Practice Address - Phone:330-636-1741
Practice Address - Fax:330-948-0880
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406098-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0184210Medicaid