Basic Information
| Provider Information | |||||||||
| NPI: | 1306096656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOLEY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | VIVIAN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 438 N WHITE RD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951271439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082546848 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 438 N WHITE RD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951271439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082546848 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 03/20/2017 | ||||||||
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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 | 104100000X | 34174 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 76107 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1306096656 | 01 | CA | UNKNOWN | OTHER |