Provider Demographics
NPI:1700421674
Name:COOPER, LARETTE DENISE (BA)
Entity Type:Individual
Prefix:
First Name:LARETTE
Middle Name:DENISE
Last Name:COOPER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17860 WEXFORD TER APT 1H
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3018
Mailing Address - Country:US
Mailing Address - Phone:917-312-2620
Mailing Address - Fax:
Practice Address - Street 1:4277 65TH PL
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5054
Practice Address - Country:US
Practice Address - Phone:516-755-7878
Practice Address - Fax:718-334-0057
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY418588239OtherDRIVER'S LICENSE