1104364603 NPI number — JUDIET COOPER MASTER, MENTAL HEALT

Table of content: JUDIET COOPER MASTER, MENTAL HEALT (NPI 1104364603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104364603 NPI number — JUDIET COOPER MASTER, MENTAL HEALT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
JUDIET
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASTER, MENTAL HEALT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COOPER
Provider Other First Name:
JUDIET
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MASTER, MENTAL HEALT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1104364603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 MILL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29020-4738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-432-6902
Provider Business Mailing Address Fax Number:
803-432-6860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 MILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29020-4738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-432-6902
Provider Business Practice Location Address Fax Number:
803-432-6890
Provider Enumeration Date:
02/03/2017

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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