Provider Demographics
NPI:1639660905
Name:COOPER, TRACY IRENETTE (LCAS A)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:IRENETTE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LCAS A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 KATHERINE TRL
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-9362
Mailing Address - Country:US
Mailing Address - Phone:252-822-1243
Mailing Address - Fax:
Practice Address - Street 1:130 JONES RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804
Practice Address - Country:US
Practice Address - Phone:252-443-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15432101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)