Provider Demographics
NPI:1700412012
Name:COOPER, AUDRA (BA, ADC, RDS)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:BA, ADC, RDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4628
Mailing Address - Country:US
Mailing Address - Phone:479-434-6266
Mailing Address - Fax:
Practice Address - Street 1:612 SOUTH 21ST STREET
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3319
Practice Address - Country:US
Practice Address - Phone:479-785-4083
Practice Address - Fax:479-434-6248
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10148-M104100000X
101YA0400X
AR10148C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)