Provider Demographics
NPI:1356650030
Name:COOPER, DALE PHILLIP (CACI, CACII)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:PHILLIP
Last Name:COOPER
Suffix:
Gender:M
Credentials:CACI, CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 SHADY OAK LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-9112
Mailing Address - Country:US
Mailing Address - Phone:843-669-2496
Mailing Address - Fax:
Practice Address - Street 1:510 E CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4312
Practice Address - Country:US
Practice Address - Phone:843-332-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0909044101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)