Healthcare Provider Details

I. General information

NPI: 1265962013
Provider Name (Legal Business Name): TRACY COOPER ED. S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 ORA AVE SE
ATLANTA GA
30316-2146
US

IV. Provider business mailing address

652 ORA AVE SE
ATLANTA GA
30316-2146
US

V. Phone/Fax

Practice location:
  • Phone: 470-222-5220
  • Fax:
Mailing address:
  • Phone: 470-222-5220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number657591
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: