Basic Information
| Provider Information | |||||||||
| NPI: | 1053473165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | ACT PROGRAM | ||||||||
| Address2: | 430 NIAGARA STREET | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168562587 | ||||||||
| FaxNumber: | 7168562608 | ||||||||
| Practice Location | |||||||||
| Address1: | ACT PROGRAM | ||||||||
| Address2: | 430 NIAGARA STREET | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168562587 | ||||||||
| FaxNumber: | 7168562608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 073339 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 073339 | 01 | NY | LMSW | OTHER |