Provider Demographics
NPI:1225501844
Name:COOPER, SAMANTHA JOLENE (LMFT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOLENE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1443
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95252-1443
Mailing Address - Country:US
Mailing Address - Phone:209-395-0955
Mailing Address - Fax:
Practice Address - Street 1:23 WEST SAINT CHARLES
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-395-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104493106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist