Provider Demographics
NPI:1154812139
Name:COOPER, MEGAN MERCEDES
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:MERCEDES
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 1:8968 SE 78TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-9299
Mailing Address - Country:US
Mailing Address - Phone:971-200-9790
Mailing Address - Fax:
Practice Address - Street 1:912 NE KELLY AVE # 100C
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5629
Practice Address - Country:US
Practice Address - Phone:503-912-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician