Healthcare Provider Details

I. General information

NPI: 1215579990
Provider Name (Legal Business Name): ELLEN COOPERRIDER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 PARK AVE STE 205
ORANGE PARK FL
32073-5573
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 904-308-3751
  • Fax: 904-308-6890
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW15691
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: