Provider Demographics
NPI:1760603823
Name:COOPER, CARRIE ANNE (MFT)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:ANNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 PORCH STREET
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503
Mailing Address - Country:US
Mailing Address - Phone:951-279-7425
Mailing Address - Fax:
Practice Address - Street 1:27720 JEFFERSON AVE.
Practice Address - Street 2:STE. 110
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590
Practice Address - Country:US
Practice Address - Phone:951-506-0864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43208106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist