Provider Demographics
NPI:1134200405
Name:COOPER, ILENE L (LCSW-C)
Entity type:Individual
Prefix:MS
First Name:ILENE
Middle Name:L
Last Name:COOPER
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3043 S MEADOW CT
Mailing Address - Street 2:PATIENT ACCOUNTING
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5162
Mailing Address - Country:US
Mailing Address - Phone:770-833-7318
Mailing Address - Fax:770-552-6783
Practice Address - Street 1:2790 SANDY PLAINS RD STE 203
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-4377
Practice Address - Country:US
Practice Address - Phone:770-833-7318
Practice Address - Fax:770-833-7318
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0033121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical