Provider Demographics
NPI:1821459397
Name:COOPER, REBECCA LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LEE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:LEE
Other - Last Name:SZUSTAKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1990 E. LOHMAN AVE
Mailing Address - Street 2:STE.214
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:575-556-4580
Mailing Address - Fax:575-800-0385
Practice Address - Street 1:1990 E. LOHMAN AVE
Practice Address - Street 2:STE.214
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:575-556-4580
Practice Address - Fax:575-800-0385
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-09321104100000X
NMLCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29954002Medicaid