Provider Demographics
NPI:1316437205
Name:COOPER, KELLIE (LLP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:COOPER-SECREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:835 MASON ST STE B220
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:835 MASON ST STE B220
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2262
Practice Address - Country:US
Practice Address - Phone:313-561-9064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016322103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical