Provider Demographics
NPI:1831261619
Name:COOPER, LAURIE (LCSW)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
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:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-0120
Mailing Address - Country:US
Mailing Address - Phone:860-429-2928
Mailing Address - Fax:860-429-2949
Practice Address - Street 1:1066 STORRS RD
Practice Address - Street 2:
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06268-2648
Practice Address - Country:US
Practice Address - Phone:860-429-2928
Practice Address - Fax:860-429-2949
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0039531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD300076553OtherMEDICARE PTAN