Provider Demographics
NPI:1750756524
Name:COOPER, KATRINA
Entity type:Individual
Prefix:
First Name:KATRINA
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 1:1115 N COLUMBIA AVE
Mailing Address - Street 2:UNIT 4
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-6825
Mailing Address - Country:US
Mailing Address - Phone:800-317-0364
Mailing Address - Fax:
Practice Address - Street 1:2830 BURTONS FERRY HWY
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-4513
Practice Address - Country:US
Practice Address - Phone:800-317-0364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006513101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional