Healthcare Provider Details

I. General information

NPI: 1023777042
Provider Name (Legal Business Name): SONIA COOPER PHD, LCP, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 N BROADVIEW AVE
LOMBARD IL
60148-2121
US

IV. Provider business mailing address

67 N BROADVIEW AVE
LOMBARD IL
60148-2121
US

V. Phone/Fax

Practice location:
  • Phone: 630-699-3130
  • Fax:
Mailing address:
  • Phone: 630-699-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009842
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: