MEDICARE: MOLLY COOPER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW21612	CA

General Provider Information

NPI Number	:	1205459617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY COOPER LCSW

Provider Business Mailing Address
First Line	:	4739 CAMELLIA AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-1105
Country	:	US
Telephone Number	:	310-893-4584
Fax Number	:

Provider Business Practice Location Address
First Line	:	4739 CAMELLIA AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-1105
Country	:	US
Telephone Number	:	310-893-4584
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2020
Last Update Date	:	05/19/2020

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