Provider Demographics
NPI:1033501911
Name:COOPER, CLARENCE (EDD, BCBA)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:EDD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 N STATE ROAD 7 STE 300
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5867
Mailing Address - Country:US
Mailing Address - Phone:561-323-6593
Mailing Address - Fax:
Practice Address - Street 1:1645 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5428
Practice Address - Country:US
Practice Address - Phone:772-773-1975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 106S00000X, 171M00000X
1-24-70821103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator