Healthcare Provider Details

I. General information

NPI: 1710434543
Provider Name (Legal Business Name): THEODORE COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3612 PERA AVE
EL PASO TX
79905-2412
US

IV. Provider business mailing address

3607 RIVERA AVE
EL PASO TX
79905-2415
US

V. Phone/Fax

Practice location:
  • Phone: 915-533-7057
  • Fax: 915-533-7158
Mailing address:
  • Phone: 915-533-7057
  • Fax: 915-533-7158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35075
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: