Provider Demographics
NPI:1881940559
Name:COOPER, MYCHAL
Entity type:Individual
Prefix:
First Name:MYCHAL
Middle Name:
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 1:441 WALNUT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5878
Mailing Address - Country:US
Mailing Address - Phone:270-312-5386
Mailing Address - Fax:
Practice Address - Street 1:4751 BEST RD STE 400R
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30337-5609
Practice Address - Country:US
Practice Address - Phone:470-775-3195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0069281041C0700X
NV11652-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical