Provider Demographics
NPI:1801812672
Name:COOPER, COURTNEY R (LCSW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:R
Last Name:COOPER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 JOHNSTON RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-4558
Mailing Address - Country:US
Mailing Address - Phone:704-999-4619
Mailing Address - Fax:
Practice Address - Street 1:10801 JOHNSTON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-4558
Practice Address - Country:US
Practice Address - Phone:704-999-4619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0044921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003587Medicaid