Healthcare Provider Details

I. General information

NPI: 1255163549
Provider Name (Legal Business Name): BENJAMIN M COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7040 LAREDO ST STE J&K
LAS VEGAS NV
89117-3000
US

IV. Provider business mailing address

7040 LAREDO ST STE J&K
LAS VEGAS NV
89117-3000
US

V. Phone/Fax

Practice location:
  • Phone: 702-444-3933
  • Fax:
Mailing address:
  • Phone: 702-444-3933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number08048-I
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: