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General NPI Number Information
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NPI Number | 1366865370
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Entity Type | Organization
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Legal Business Name | DOGWOOD MENTAL HEALTH AND WELLNESS, LLC
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Dates
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Enumeration Date | 01/27/2014
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Last Update Date | 02/14/2014
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Provider Practice Location Address
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Address Line | 412 NORTH ST SUITE B
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City | NACOGDOCHES
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State | TX
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Zip | 75961-5077
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Country | US
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Telephone | 936-622-0993
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Fax | 936-622-0994
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Provider Business Mailing Address
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Address Line | PO BOX 632279
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City | NACOGDOCHES
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State | TX
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Zip | 75963-2279
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Country | US
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Telephone | 936-622-0993
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Fax | 936-622-0994
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. HASKELL STEPHEN COOPER
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Credential | PHD, LCSW
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Telephone | 936-622-0993
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34017
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License Number State | TX
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