Provider Demographics
NPI:1073798179
Name:COOPER, CASEY (PHD)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:CASEY
Other - Middle Name:
Other - Last Name:ACKERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:27201 PUERTA REAL
Mailing Address - Street 2:STE 300
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-7359
Mailing Address - Country:US
Mailing Address - Phone:949-420-4655
Mailing Address - Fax:
Practice Address - Street 1:27281 LAS RAMBLAS
Practice Address - Street 2:STE 200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-420-3067
Practice Address - Fax:949-305-4171
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21348103T00000X, 103TB0200X, 103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27-1865720OtherEIN