Healthcare Provider Details

I. General information

NPI: 1336745231
Provider Name (Legal Business Name): DAMEKICA N COOPER CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20200 VEACH ST
DETROIT MI
48234-3218
US

IV. Provider business mailing address

14120 15 MILE RD APT 110
STERLING HEIGHTS MI
48312-5561
US

V. Phone/Fax

Practice location:
  • Phone: 586-420-0367
  • Fax:
Mailing address:
  • Phone: 313-627-1868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number230005622360101
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: