Provider Demographics
NPI:1639862436
Name:COOPER, CARL WESLEY SR
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:WESLEY
Last Name:COOPER
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 SW 65TH PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-9547
Mailing Address - Country:US
Mailing Address - Phone:561-385-0832
Mailing Address - Fax:
Practice Address - Street 1:15681 N US HIGHWAY 301
Practice Address - Street 2:
Practice Address - City:CITRA
Practice Address - State:FL
Practice Address - Zip Code:32113-3154
Practice Address - Country:US
Practice Address - Phone:352-595-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)