Healthcare Provider Details

I. General information

NPI: 1497077424
Provider Name (Legal Business Name): MRS. BOBBY JEAN COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BOBBY JEAN COOPER LMHC

II. Dates (important events)

Enumeration Date: 02/17/2010
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12309 BRETON OAK LN
RIVERVIEW FL
33569-8227
US

IV. Provider business mailing address

12309 BRETON OAK LN
RIVERVIEW FL
33569-8227
US

V. Phone/Fax

Practice location:
  • Phone: 813-245-5549
  • Fax:
Mailing address:
  • Phone: 813-245-5549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 9004
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: