Provider Demographics
NPI:1134094543
Name:COOPER, AMBER ANNE
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:ANNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6090 PAT ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-9669
Mailing Address - Country:US
Mailing Address - Phone:231-335-1718
Mailing Address - Fax:
Practice Address - Street 1:6995 W 48TH ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-9506
Practice Address - Country:US
Practice Address - Phone:231-335-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-07
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451024620101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty