Provider Demographics
NPI:1578113056
Name:COOPER, SHAN-A KRISTIN
Entity Type:Individual
Prefix:
First Name:SHAN-A
Middle Name:KRISTIN
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 1:506 ELM ST NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-8503
Mailing Address - Country:US
Mailing Address - Phone:770-852-0885
Mailing Address - Fax:
Practice Address - Street 1:506 ELM ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-8503
Practice Address - Country:US
Practice Address - Phone:770-852-0885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician