1194275289 NPI number — GOLDIE LYNN COOPER LMSW,QMHP,QIDP,CMHP

Table of content: GOLDIE LYNN COOPER LMSW,QMHP,QIDP,CMHP (NPI 1194275289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194275289 NPI number — GOLDIE LYNN COOPER LMSW,QMHP,QIDP,CMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
GOLDIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW,QMHP,QIDP,CMHP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALLEN
Provider Other First Name:
GOLDIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194275289
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3865 S MACKINAC TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAULT SAINTE MARIE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49783-9286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-635-3725
Provider Business Mailing Address Fax Number:
906-632-1163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3865 S MACKINAC TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAULT SAINTE MARIE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49783-9286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-635-3725
Provider Business Practice Location Address Fax Number:
906-632-1163
Provider Enumeration Date:
10/12/2016

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: 1041C0700X , with the licence number:  68021100186 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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