Provider Demographics
NPI:1740279629
Name:COOPER, BRENDA LYNN (MSW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:COOPER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720
Mailing Address - Country:US
Mailing Address - Phone:978-314-7301
Mailing Address - Fax:
Practice Address - Street 1:76 SUMMER ST
Practice Address - Street 2:SUITE 145
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5783
Practice Address - Country:US
Practice Address - Phone:978-342-6070
Practice Address - Fax:978-343-9408
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1037311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAR42056Medicare UPIN
MAP02658Medicare ID - Type Unspecified