Basic Information
| Provider Information | |||||||||
| NPI: | 1942368568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 269 COLERIDGE ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112354122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189348208 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 COUNTY ROAD 516 | ||||||||
| Address2: | |||||||||
| City: | OLD BRIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088571421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322548200 | ||||||||
| FaxNumber: | 7326130017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 35S100214700 | NJ | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0435007 | 05 | NJ | MEDICAID |