MEDICARE: DR. PHYLLIS JANE GRAVES-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	012874	NY

General Provider Information

NPI Number	:	1124246434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHYLLIS JANE GRAVES-COOPER PH.D.

Provider Business Mailing Address
First Line	:	1102 SCARBOROUGH DR
Second Line	:
City	:	BREWSTER
State	:	NY
Zip	:	10509-6561
Country	:	US
Telephone Number	:	845-278-0444
Fax Number	:	845-278-0444

Provider Business Practice Location Address
First Line	:	967 ROUTE 22
Second Line	:
City	:	BREWSTER
State	:	NY
Zip	:	10509-1526
Country	:	US
Telephone Number	:	845-529-3900
Fax Number	:	845-278-0444

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	12/27/2013

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