=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073798179
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY COOPER PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2008
-----------------------------------------------------
Last Update Date | 10/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27281 LAS RAMBLAS STE 200
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-420-3067
-----------------------------------------------------
Fax | 949-305-4171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27201 PUERTA REAL STE 300
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-7359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-420-4655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY21348
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number | PSY21348
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TE1100X
-----------------------------------------------------
Taxonomy Name | Exercise & Sports Psychologist
-----------------------------------------------------
License Number | PSY21348
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------