Healthcare Provider Details

I. General information

NPI: 1043148133
Provider Name (Legal Business Name): SAMUEL WILSON COOPER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20330 WHITES FERRY RD
POOLESVILLE MD
20837-9572
US

IV. Provider business mailing address

20330 WHITES FERRY RD
POOLESVILLE MD
20837-9572
US

V. Phone/Fax

Practice location:
  • Phone: 240-417-8137
  • Fax:
Mailing address:
  • Phone: 240-417-8137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL COOPER
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW-C
Phone: 301-704-5916