Basic Information
| Provider Information | |||||||||
| NPI: | 1598867566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOLEY | ||||||||
| FirstName: | JOHNNIE | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORBES | ||||||||
| OtherFirstName: | JOHNNIE | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 270 CAGNEY LN | ||||||||
| Address2: | #101 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926632673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144806743 | ||||||||
| FaxNumber: | 7145684933 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W 5TH ST | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148342125 | ||||||||
| FaxNumber: | 7145684933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS20797 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.