=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437957669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COOPER YOUNG THERAPIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2025
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 832 S COOPER ST
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-383-3561
-----------------------------------------------------
Fax | 901-791-4390
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 832 S COOPER ST
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-383-3561
-----------------------------------------------------
Fax | 901-791-4390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EARLE G DONELSON
-----------------------------------------------------
Credential | PSYCHOLOGIST
-----------------------------------------------------
Telephone | 901-383-3561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------