Provider Demographics
NPI:1427394584
Name:COOPER, SHELLEY LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:LEE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:LEE
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:85 OLD LONG RIDGE RD
Mailing Address - Street 2:SUITE A-5
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-1641
Mailing Address - Country:US
Mailing Address - Phone:203-722-4405
Mailing Address - Fax:203-609-8034
Practice Address - Street 1:85 OLD LONG RIDGE RD
Practice Address - Street 2:SUITE A-5
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06903-1641
Practice Address - Country:US
Practice Address - Phone:203-722-4405
Practice Address - Fax:203-609-8034
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0079821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008051253Medicaid