Provider Demographics
NPI:1902297252
Name:COOLEY, DARYL (MS)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:COOLEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37207-5905
Mailing Address - Country:US
Mailing Address - Phone:508-308-1623
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 654
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:857-264-0965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AR202174103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307576Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD
MA1303295Medicaid
MAY10086Medicare PIN