Healthcare Provider Details

I. General information

NPI: 1659844967
Provider Name (Legal Business Name): CHAMPAIGN AUTUMN COOPER QMHS BA CMS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W MARKET ST
AKRON OH
44303-1411
US

IV. Provider business mailing address

611 W MARKET ST
AKRON OH
44303-1411
US

V. Phone/Fax

Practice location:
  • Phone: 330-996-4600
  • Fax: 330-564-9296
Mailing address:
  • Phone: 330-996-4600
  • Fax: 330-564-9296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: