Provider Demographics
NPI:1073914867
Name:COOPER, SUSAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 PASEO DE PERALTA STE 9
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2775
Mailing Address - Country:US
Mailing Address - Phone:505-603-9184
Mailing Address - Fax:
Practice Address - Street 1:924 PASEO DE PERALTA STE 9
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2775
Practice Address - Country:US
Practice Address - Phone:505-603-9184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW122271041C0700X
NMC090681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical