Healthcare Provider Details

I. General information

NPI: 1104837996
Provider Name (Legal Business Name): STEWART E. COOPER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 LAPORTE AVE
VALPARAISO IN
46383-4534
US

IV. Provider business mailing address

211 LEGEND DR APARTMENT 203
VALPARAISO IN
46383-6696
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-5002
  • Fax: 219-464-6865
Mailing address:
  • Phone: 219-464-0311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20040467
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: