MEDICARE: DAVID 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	104100000X	Social Worker	34000392	IN

General Provider Information

NPI Number	:	1902862410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID COOPER LCSW

Provider Business Mailing Address
First Line	:	415 E COOK RD
Second Line	:	STE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3636
Country	:	US
Telephone Number	:	260-489-6030
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 E COOK RD
Second Line	:	STE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3636
Country	:	US
Telephone Number	:	260-489-6030
Fax Number	:

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

Provider Enumeration Date	:	04/24/2006
Last Update Date	:	03/28/2008

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Directions to “ DAVID COOPER LCSW” Practice Location

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