1124246434 NPI number — DR. PHYLLIS JANE GRAVES-COOPER PH.D.

Table of content: DR. PHYLLIS JANE GRAVES-COOPER PH.D. (NPI 1124246434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124246434 NPI number — DR. PHYLLIS JANE GRAVES-COOPER PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAVES-COOPER
Provider First Name:
PHYLLIS
Provider Middle Name:
JANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124246434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
967 ROUTE 22
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREWSTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10509-1526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-529-3900
Provider Business Practice Location Address Fax Number:
845-278-0444
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  012874 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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