Provider Demographics
NPI:1811362676
Name:COOPER, TINA (MSW, LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:MSW, LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2287
Mailing Address - Country:US
Mailing Address - Phone:630-377-6613
Mailing Address - Fax:630-377-6225
Practice Address - Street 1:110 E COUNTRYSIDE PKWY STE C
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1814
Practice Address - Country:US
Practice Address - Phone:630-553-1600
Practice Address - Fax:630-553-7993
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490181361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical