Provider Demographics
NPI:1710056726
Name:COOPER, KERRY (CASAC)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31094
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06154-0001
Mailing Address - Country:US
Mailing Address - Phone:518-952-8140
Mailing Address - Fax:518-952-8287
Practice Address - Street 1:3584 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1006
Practice Address - Country:US
Practice Address - Phone:718-653-1537
Practice Address - Fax:718-882-1426
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12174101YA0400X
NY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420795Medicaid