Healthcare Provider Details

I. General information

NPI: 1679076806
Provider Name (Legal Business Name): CLAY M COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8423 MARKET ST
BOARDMAN OH
44512-6778
US

IV. Provider business mailing address

8401 MARKET ST
YOUNGSTOWN OH
44512-6725
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-5490
  • Fax: 330-965-5491
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.1700347
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008999RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: