Provider Demographics
NPI:1336807999
Name:COOPER, ANGELA ELAINE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ELAINE
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 1:4450 RIVANNA RIVER WAY # 4615
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4441
Mailing Address - Country:US
Mailing Address - Phone:757-389-2462
Mailing Address - Fax:
Practice Address - Street 1:4450 RIVANNA RIVER WAY # 4615
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4441
Practice Address - Country:US
Practice Address - Phone:757-389-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst