Provider Demographics
NPI:1558933630
Name:COOPER, CAMRYN ELISE
Entity Type:Individual
Prefix:
First Name:CAMRYN
Middle Name:ELISE
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 1:11537 WINDING RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-4447
Mailing Address - Country:US
Mailing Address - Phone:804-252-6927
Mailing Address - Fax:
Practice Address - Street 1:11537 WINDING RIVER RD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE FORGE
Practice Address - State:VA
Practice Address - Zip Code:23140-4447
Practice Address - Country:US
Practice Address - Phone:804-252-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician