Provider Demographics
NPI:1033459557
Name:COOPER LOPEZ, NICOLE D (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:D
Last Name:COOPER LOPEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12436
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0619
Mailing Address - Country:US
Mailing Address - Phone:520-369-2511
Mailing Address - Fax:
Practice Address - Street 1:109 W 2ND ST
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4406
Practice Address - Country:US
Practice Address - Phone:520-369-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4353103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical