Healthcare Provider Details

I. General information

NPI: 1053473165
Provider Name (Legal Business Name): EDWARD JOSEPH COOPER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ACT PROGRAM 430 NIAGARA STREET
BUFFALO NY
14201
US

IV. Provider business mailing address

ACT PROGRAM 430 NIAGARA STREET
BUFFALO NY
14201
US

V. Phone/Fax

Practice location:
  • Phone: 716-856-2587
  • Fax: 716-856-2608
Mailing address:
  • Phone: 716-856-2587
  • Fax: 716-856-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number073339
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: