MEDICARE: DEBORAH COOPER PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	0810002740	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	188531	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1033167606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH COOPER PH.D

Provider Business Mailing Address
First Line	:	PO BOX 765
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-0765
Country	:	US
Telephone Number	:	540-373-3223
Fax Number	:	540-371-3753

Provider Business Practice Location Address
First Line	:	600 JACKSON ST
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-5719
Country	:	US
Telephone Number	:	540-373-3223
Fax Number	:	540-371-3753

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	07/08/2007

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