Provider Demographics
NPI:1821577636
Name:COOPER, ASHLEY NICOLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
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 1:4210 E FLETCHER AVE # B-208A
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-5844
Mailing Address - Country:US
Mailing Address - Phone:386-847-4442
Mailing Address - Fax:
Practice Address - Street 1:4210 E FLETCHER AVE # B-208A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-5844
Practice Address - Country:US
Practice Address - Phone:386-847-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL519106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician