Healthcare Provider Details

I. General information

NPI: 1205063310
Provider Name (Legal Business Name): MADONNA COOPER POOL MS., LCADC, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3783 PLEASANT VALLEY RD
OAKLAND MD
21550-5609
US

IV. Provider business mailing address

331 EARL HAUSER RD
OAKLAND MD
21550-2418
US

V. Phone/Fax

Practice location:
  • Phone: 301-616-7469
  • Fax:
Mailing address:
  • Phone: 301-334-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA201
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC1504
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number60402
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: