Provider Demographics
NPI:1083010193
Name:COOPER, LACY (MS)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 N PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5970
Mailing Address - Country:US
Mailing Address - Phone:503-508-5819
Mailing Address - Fax:
Practice Address - Street 1:3880 SE 8TH AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3772
Practice Address - Country:US
Practice Address - Phone:503-545-6798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3445101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional