Provider Demographics
NPI:1871607689
Name:COPPER LEAF COUNSELING LLC
Entity type:Organization
Organization Name:COPPER LEAF COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE EDIN
Authorized Official - Last Name:BROWNING
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:480-703-7950
Mailing Address - Street 1:6344 E BROADWAY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1634
Mailing Address - Country:US
Mailing Address - Phone:480-703-7950
Mailing Address - Fax:480-218-1895
Practice Address - Street 1:6344 E BROADWAY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1634
Practice Address - Country:US
Practice Address - Phone:480-703-7950
Practice Address - Fax:480-218-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW 24091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ112732Medicare PIN