MEDICARE: MRS. ANDREA DAWN COOPER LPC, LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	11640	TX
2	101YP2500X	Professional Counselor	64619	TX

General Provider Information

NPI Number	:	1306266424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANDREA DAWN COOPER LPC, LCDC

Provider Business Mailing Address
First Line	:	5117 MEADOW PLACE DR
Second Line	:
City	:	LA PORTE
State	:	TX
Zip	:	77571-2818
Country	:	US
Telephone Number	:	713-824-2114
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 FM 2004 RD
Second Line	:
City	:	TEXAS CITY
State	:	TX
Zip	:	77591-2199
Country	:	US
Telephone Number	:	713-824-2114
Fax Number	:

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

Provider Enumeration Date	:	04/17/2014
Last Update Date	:	04/17/2014

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