Basic Information
| Provider Information | |||||||||
| NPI: | 1124067038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANTAM COOPER | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MAINE ST STE A | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439192 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 MAINE ST STE A | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439192 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 05/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LCP 0109 | KS | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.