Provider Demographics
NPI:1003044306
Name:COOPER, STACIE LYN (PSYD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYN
Last Name:COOPER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LYN COOPER
Other - Last Name:ESHELMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:26891 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-2692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26891 SPRING ST
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2692
Practice Address - Country:US
Practice Address - Phone:949-361-7892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health