Provider Demographics
NPI:1639344260
Name:BRYANT COOPER, CANDACE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:BRYANT COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:BRYANT
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 23884
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-0884
Mailing Address - Country:US
Mailing Address - Phone:253-331-5050
Mailing Address - Fax:
Practice Address - Street 1:33919 9TH AVE S STE 209
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6724
Practice Address - Country:US
Practice Address - Phone:253-230-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00006516101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health