Provider Demographics
NPI:1851945943
Name:COOPER, KELLY (LMHC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 WILDROSE CIR
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-9178
Mailing Address - Country:US
Mailing Address - Phone:830-734-4000
Mailing Address - Fax:
Practice Address - Street 1:591 WILDROSE CIR
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-9178
Practice Address - Country:US
Practice Address - Phone:830-734-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-28
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60828608101YM0800X
WALH61228753101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty