Healthcare Provider Details

I. General information

NPI: 1134169154
Provider Name (Legal Business Name): ANTIONETTE T COOPER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N MILLER RD
FAIRLAWN OH
44333-3770
US

IV. Provider business mailing address

150 N MILLER RD STE 450E1
FAIRLAWN OH
44333-3770
US

V. Phone/Fax

Practice location:
  • Phone: 234-457-2841
  • Fax:
Mailing address:
  • Phone: 234-457-2841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5307
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: