Provider Demographics
NPI:1699703835
Name:COOPER, CHARLES MARCUS (PHD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARCUS
Last Name:COOPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MED TECH PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4007
Mailing Address - Country:US
Mailing Address - Phone:423-232-6120
Mailing Address - Fax:
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-232-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1084103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3584891Medicaid
TN7241087OtherAETNA
TN186690OtherANTHEM (KPT)
TNTN0107OtherJOHN DEERE
TN14722OtherCARITEN
TN186693OtherANTHEM JC
TN4010675OtherBLUE CROSS (MENTAL HEALTH
TN4104023OtherBLUE CROSS (MEDICAL)
TN186690OtherANTHEM (KPT)