Healthcare Provider Details

I. General information

NPI: 1316437205
Provider Name (Legal Business Name): KELLIE COOPER LP, HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLIE COOPER-SECREST

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 E STATE BLVD
FORT WAYNE IN
46805-4700
US

IV. Provider business mailing address

3010 E STATE BLVD
FORT WAYNE IN
46805-4700
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20043895
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016322
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: