Healthcare Provider Details

I. General information

NPI: 1992469605
Provider Name (Legal Business Name): ZACHARY WYMAN COOPER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 DANTIGNAC ST
AUGUSTA GA
30901-2788
US

IV. Provider business mailing address

PO BOX 2344
AUGUSTA GA
30903-2344
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-0607
  • Fax: 706-396-1461
Mailing address:
  • Phone: 706-922-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW007754
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: