Basic Information
| Provider Information | |||||||||
| NPI: | 1548392715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | FRANCES | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2165 HISTORIC DECATUR RD | ||||||||
| Address2: | UNIT 23 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921066055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196928207 | ||||||||
| FaxNumber: | 6195424060 | ||||||||
| Practice Location | |||||||||
| Address1: | 3853 ROSECRANS STREET | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196928207 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
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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 | 1041C0700X | 22653 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 22653 | 01 | CA | LCSW | OTHER | 6847 | 01 | CA | UNITED BEHAVIORAL HEALTH | OTHER |