Healthcare Provider Details

I. General information

NPI: 1073967683
Provider Name (Legal Business Name): RYAN COOPER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W MADRONE ST
ROSEBURG OR
97470-3090
US

IV. Provider business mailing address

621 W MADRONE ST
ROSEBURG OR
97470-3090
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-3532
  • Fax:
Mailing address:
  • Phone: 541-440-3532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA4369
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: