Provider Demographics
NPI:1912485772
Name:COOPER, CHRISTAL JUNE (LMSW)
Entity Type:Individual
Prefix:
First Name:CHRISTAL
Middle Name:JUNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11510 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5267
Mailing Address - Country:US
Mailing Address - Phone:208-921-9931
Mailing Address - Fax:
Practice Address - Street 1:823 PARKCENTRE WAY
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1783
Practice Address - Country:US
Practice Address - Phone:208-475-5065
Practice Address - Fax:208-463-0972
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-28189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional