MEDICARE: TINA COOPER LCSW, CADC

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	149.022222	IL

General Provider Information

NPI Number	:	1952054785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA COOPER LCSW, CADC

Provider Business Mailing Address
First Line	:	300 CIRCLE AVE APT 6H
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-1667
Country	:	US
Telephone Number	:	708-299-2526
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 N WACKER DR FL 17
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60606-7384
Country	:	US
Telephone Number	:	312-898-6721
Fax Number	:

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

Provider Enumeration Date	:	02/01/2022
Last Update Date	:	02/01/2022

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