Provider Demographics
NPI:1508406687
Name:COOPER, KSENIA
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-2415
Mailing Address - Country:US
Mailing Address - Phone:318-868-3093
Mailing Address - Fax:
Practice Address - Street 1:3939 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108-2415
Practice Address - Country:US
Practice Address - Phone:318-868-3093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA813288219Medicaid