Provider Demographics
NPI:1942742374
Name:COOPER, DEION (LMSW)
Entity Type:Individual
Prefix:MR
First Name:DEION
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-2910
Mailing Address - Country:US
Mailing Address - Phone:203-787-2207
Mailing Address - Fax:
Practice Address - Street 1:501 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-2910
Practice Address - Country:US
Practice Address - Phone:203-787-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT29621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT06-0667607Medicaid