MEDICARE: GUY COOPER PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	CP0079	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12038643	OTHER	NV	CAQH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790108777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUY COOPER PLLC

Provider Business Mailing Address
First Line	:	8228 CHIMNEY BLUFFS ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89085-4412
Country	:	US
Telephone Number	:	702-645-4919
Fax Number	:	702-645-4919

Provider Business Practice Location Address
First Line	:	8228 CHIMNEY BLUFFS ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89085-4412
Country	:	US
Telephone Number	:	702-645-4919
Fax Number	:	702-645-4919

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	GUY CALDERON COOPER
Credential	:	M.S., LCPC
Telephone Number	:	702-645-4919

Provider Enumeration Date	:	01/28/2014
Last Update Date	:	01/28/2014

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