Healthcare Provider Details

I. General information

NPI: 1053177808
Provider Name (Legal Business Name): KATHERINE MARIE COOPER LCPC, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8124 STATE ROUTE 140
EDWARDSVILLE IL
62025-6114
US

IV. Provider business mailing address

8124 STATE ROUTE 140
EDWARDSVILLE IL
62025-6114
US

V. Phone/Fax

Practice location:
  • Phone: 567-337-9937
  • Fax:
Mailing address:
  • Phone: 567-337-9937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number101500
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8321003
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number70080587
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC11493
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1350-4-1-24-600
License Number StateND
# 6
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.018151
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: