Healthcare Provider Details

I. General information

NPI: 1306218094
Provider Name (Legal Business Name): CHRISTINA MARIE COOPER-GOMM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINA MARIE COOPER LCSW

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 E 12300 S STE C530
DRAPER UT
84020-7976
US

IV. Provider business mailing address

138 E 12300 S STE C530
DRAPER UT
84020-7976
US

V. Phone/Fax

Practice location:
  • Phone: 385-360-1961
  • Fax:
Mailing address:
  • Phone: 385-360-1961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104936943502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: