1073798179 NPI number — CASEY COOPER PHD

Table of content: CASEY COOPER PHD (NPI 1073798179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073798179 NPI number — CASEY COOPER PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
CASEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ACKERMAN
Provider Other First Name:
CASEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1073798179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27201 PUERTA REAL
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
MISSION VIEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92691-7359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-420-4655
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27281 LAS RAMBLAS
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
MISSION VIEJO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-420-3067
Provider Business Practice Location Address Fax Number:
949-305-4171
Provider Enumeration Date:
01/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY21348 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X , with the licence number: PSY21348 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TE1100X , with the licence number: PSY21348 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)