Healthcare Provider Details

I. General information

NPI: 1376948976
Provider Name (Legal Business Name): MARIE LOUISE COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5063 MAPLE RD
VACAVILLE CA
95687-9468
US

IV. Provider business mailing address

5050 LAGUNA BLVD STE 112
ELK GROVE CA
95758-4151
US

V. Phone/Fax

Practice location:
  • Phone: 540-993-3422
  • Fax:
Mailing address:
  • Phone: 540-993-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: