Provider Demographics
NPI:1962627844
Name:COOPER, DARYL RAY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:RAY
Last Name:COOPER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 MARINA DRIVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601
Mailing Address - Country:US
Mailing Address - Phone:541-891-4402
Mailing Address - Fax:541-883-3524
Practice Address - Street 1:2330 MARINA DR
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601
Practice Address - Country:US
Practice Address - Phone:541-883-3471
Practice Address - Fax:541-883-3524
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL4111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR026825000OtherBCBS PROVIDER #
OR090450Medicaid