Healthcare Provider Details

I. General information

NPI: 1609337344
Provider Name (Legal Business Name): SAMUEL COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
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 Number29186
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: