Healthcare Provider Details

I. General information

NPI: 1437957669
Provider Name (Legal Business Name): COOPER YOUNG THERAPIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 S COOPER ST
MEMPHIS TN
38104-5409
US

IV. Provider business mailing address

832 S COOPER ST
MEMPHIS TN
38104-5409
US

V. Phone/Fax

Practice location:
  • Phone: 901-383-3561
  • Fax: 901-791-4390
Mailing address:
  • Phone: 901-383-3561
  • Fax: 901-791-4390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: EARLE G DONELSON
Title or Position: OWNER
Credential: PSYCHOLOGIST
Phone: 901-383-3561