Provider Demographics
NPI:1043907900
Name:COOPER, BRYAN (QMHS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5040 GREENHURST DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-1124
Mailing Address - Country:US
Mailing Address - Phone:216-702-8542
Mailing Address - Fax:
Practice Address - Street 1:5040 GREENHURST DR
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1124
Practice Address - Country:US
Practice Address - Phone:216-702-8542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHRF347418172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171M00000XOther Service ProvidersCase Manager/Care Coordinator