Provider Demographics
NPI:1205330362
Name:COOPER, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-1498
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-1498
Practice Address - Country:US
Practice Address - Phone:716-828-9699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007961101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health