Provider Demographics
NPI:1114539285
Name:COOPER, STACEY MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5145 LONG DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66216-1455
Mailing Address - Country:US
Mailing Address - Phone:913-378-6312
Mailing Address - Fax:
Practice Address - Street 1:110 S CHERRY ST STE 200
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-3441
Practice Address - Country:US
Practice Address - Phone:913-378-6312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS8330104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker