Provider Demographics
NPI:1891032322
Name:COOPER, CANDICE P (PHD)
Entity Type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:P
Last Name:COOPER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LANIER AVE W
Mailing Address - Street 2:SUITE 908
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7636
Mailing Address - Country:US
Mailing Address - Phone:716-348-9483
Mailing Address - Fax:
Practice Address - Street 1:500 LANIER AVE W
Practice Address - Street 2:SUITE 908
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7636
Practice Address - Country:US
Practice Address - Phone:678-561-4468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001322106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist