Provider Demographics
NPI:1447541537
Name:COOPER, ROXANNA ELENA (MS)
Entity type:Individual
Prefix:MRS
First Name:ROXANNA
Middle Name:ELENA
Last Name:COOPER
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 1:9445 FARNHAM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1308
Mailing Address - Country:US
Mailing Address - Phone:858-380-4676
Mailing Address - Fax:
Practice Address - Street 1:9445 FARNHAM ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1308
Practice Address - Country:US
Practice Address - Phone:858-380-4676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 390200000X
CA97765106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program