Provider Demographics
NPI:1770643348
Name:COOPER, WANDA MICHELLE
Entity Type:Individual
Prefix:MISS
First Name:WANDA
Middle Name:MICHELLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17130 SEQUOIA ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1403
Mailing Address - Country:US
Mailing Address - Phone:760-949-1939
Mailing Address - Fax:760-949-1970
Practice Address - Street 1:17130 SEQUOIA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92395-1827
Practice Address - Country:US
Practice Address - Phone:760-949-1939
Practice Address - Fax:760-949-1970
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50136106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist