Provider Demographics
NPI:1518673771
Name:COOPER, BENERANDA VASQUEZ
Entity Type:Individual
Prefix:
First Name:BENERANDA
Middle Name:VASQUEZ
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 1:8787 COMPLEX DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1453
Mailing Address - Country:US
Mailing Address - Phone:760-592-0088
Mailing Address - Fax:760-370-9236
Practice Address - Street 1:502 W ATEN RD STE 105
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-9423
Practice Address - Country:US
Practice Address - Phone:760-592-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician