Provider Demographics
NPI:1275070146
Name:COOPER, VERNARDUS
Entity Type:Individual
Prefix:
First Name:VERNARDUS
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5824 SARAZEN TRAIL
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135
Mailing Address - Country:US
Mailing Address - Phone:678-852-5524
Mailing Address - Fax:
Practice Address - Street 1:5824 SARAZEN TRL
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7640
Practice Address - Country:US
Practice Address - Phone:678-852-5524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker