Provider Demographics
NPI:1053655688
Name:COOPER, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W GOWE ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5892
Mailing Address - Country:US
Mailing Address - Phone:253-833-7444
Mailing Address - Fax:
Practice Address - Street 1:655 S ORCAS ST
Practice Address - Street 2:SUITE 122
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2648
Practice Address - Country:US
Practice Address - Phone:253-833-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60034707101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health