Provider Demographics
NPI:1982101127
Name:COOPER, BRUCE ALAN (LCDC,AADC, NCACII)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:COOPER
Suffix:
Gender:M
Credentials:LCDC,AADC, NCACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 RAMBLER DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4049
Mailing Address - Country:US
Mailing Address - Phone:956-204-9630
Mailing Address - Fax:
Practice Address - Street 1:1013 RAMBLER DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4049
Practice Address - Country:US
Practice Address - Phone:956-204-9630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2590101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2590OtherDSHS