Basic Information
| Provider Information | |||||||||
| NPI: | 1174735237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | THERESE | ||||||||
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| Credential: | CPSS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 918 | ||||||||
| Address2: | |||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295120918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434540841 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 207 COMMERCE AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436232229 | ||||||||
| FaxNumber: | 8436232553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 405127 | 05 | SC | MEDICAID |