Provider Demographics
NPI:1790293421
Name:COOPER, LYDIA S
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:S
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 1:276 BRIGHTLEAF CIR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-9508
Mailing Address - Country:US
Mailing Address - Phone:706-593-9658
Mailing Address - Fax:
Practice Address - Street 1:3015 E SKELLY DR STE 395
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6348
Practice Address - Country:US
Practice Address - Phone:918-764-8378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty