Provider Demographics
NPI:1619493970
Name:COOPERATIVE COACHING CONCEPTS
Entity Type:Organization
Organization Name:COOPERATIVE COACHING CONCEPTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:HOWE
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:727-505-2155
Mailing Address - Street 1:686 ROANOKE ST
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-8421
Mailing Address - Country:US
Mailing Address - Phone:727-505-2155
Mailing Address - Fax:727-796-0158
Practice Address - Street 1:3607 ALT 19 STE B
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-1412
Practice Address - Country:US
Practice Address - Phone:727-505-2155
Practice Address - Fax:727-796-0158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2587106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015005342Medicaid