Healthcare Provider Details

I. General information

NPI: 1487558953
Provider Name (Legal Business Name): TYHEEM DAJOHN COOPER SR. MA, MSW, LCSWA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 TURNER DR
REIDSVILLE NC
27320-5736
US

IV. Provider business mailing address

229 TURNER DR
REIDSVILLE NC
27320-5736
US

V. Phone/Fax

Practice location:
  • Phone: 336-349-2233
  • Fax: 336-634-0444
Mailing address:
  • Phone: 336-349-2233
  • Fax: 336-634-0444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024578
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: