Provider Demographics
NPI:1043563612
Name:COOPER, LEE CHARLES
Entity type:Individual
Prefix:MR
First Name:LEE
Middle Name:CHARLES
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1105
Mailing Address - Country:US
Mailing Address - Phone:510-666-9552
Mailing Address - Fax:510-666-0987
Practice Address - Street 1:1931 CENTER ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1105
Practice Address - Country:US
Practice Address - Phone:510-666-9552
Practice Address - Fax:510-666-0987
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000OtherAC BHCS CLINICIAN #