Provider Demographics
NPI:1467879643
Name:COOPER-FANUCCHI, CORALIA GUADALUPE
Entity Type:Individual
Prefix:MRS
First Name:CORALIA
Middle Name:GUADALUPE
Last Name:COOPER-FANUCCHI
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CORALIA
Other - Middle Name:GUADALUPE
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:905 MAPLE ST.
Mailing Address - Street 2:1289 LINDA MAR SHOPPING CTR
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 37TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4324
Practice Address - Country:US
Practice Address - Phone:415-531-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69637106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist