Provider Demographics
NPI:1033501911
Name:COOPER, CLARENCE (EDD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:EDD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-1646
Mailing Address - Country:US
Mailing Address - Phone:772-538-2188
Mailing Address - Fax:
Practice Address - Street 1:2500 N MILITARY TRL STE 304
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6324
Practice Address - Country:US
Practice Address - Phone:772-362-9878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
1-24-70821103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator