Healthcare Provider Details

I. General information

NPI: 1194798660
Provider Name (Legal Business Name): HENRIETTA ELIZABETH COOPER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115
US

IV. Provider business mailing address

150 GRANT ST
LEXINGTON MA
02420
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7181
  • Fax: 617-730-0185
Mailing address:
  • Phone: 781-860-9740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number150598
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: