Healthcare Provider Details

I. General information

NPI: 1073914867
Provider Name (Legal Business Name): SUSAN COOPER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 06/17/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 PASEO DE PERALTA STE 9
SANTA FE NM
87501-2775
US

IV. Provider business mailing address

924 PASEO DE PERALTA STE 9
SANTA FE NM
87501-2775
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-9184
  • Fax:
Mailing address:
  • Phone: 505-603-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12227
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC09068
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: