Provider Demographics
NPI:1871050708
Name:COOPER, KOREN (MS, LPCA)
Entity type:Individual
Prefix:
First Name:KOREN
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:MS, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 HICKORY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-4207
Mailing Address - Country:US
Mailing Address - Phone:847-913-4166
Mailing Address - Fax:
Practice Address - Street 1:9132 FISHERS POND DR UNIT D2
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-0167
Practice Address - Country:US
Practice Address - Phone:847-913-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NCA14620101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health