Healthcare Provider Details

I. General information

NPI: 1265104434
Provider Name (Legal Business Name): COOPER COUNSELING AND THERAPY SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6047 TYVOLA GLEN CIR STE 211
CHARLOTTE NC
28217-6437
US

IV. Provider business mailing address

10109 GLENBURN LN
CHARLOTTE NC
28278-6001
US

V. Phone/Fax

Practice location:
  • Phone: 980-900-9574
  • Fax: 704-780-1066
Mailing address:
  • Phone: 980-900-9574
  • Fax: 704-780-1066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. CARMAN VATRELL COOPER
Title or Position: OWNER
Credential: LCSW
Phone: 980-900-9574