Provider Demographics
NPI:1528643822
Name:COOPER, MICO BRENITTA
Entity type:Individual
Prefix:
First Name:MICO
Middle Name:BRENITTA
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10105 PLANK RD STE A
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-3707
Mailing Address - Country:US
Mailing Address - Phone:225-605-5026
Mailing Address - Fax:
Practice Address - Street 1:10105 PLANK RD STE 5
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-3707
Practice Address - Country:US
Practice Address - Phone:225-605-5026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LAAN529595101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator