Basic Information
| Provider Information | |||||||||
| NPI: | 1710434543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | THEODORE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3607 RIVERA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337057 | ||||||||
| FaxNumber: | 9155337158 | ||||||||
| Practice Location | |||||||||
| Address1: | 3612 PERA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337057 | ||||||||
| FaxNumber: | 9155337158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2016 | ||||||||
| LastUpdateDate: | 09/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 35075 | TX | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.