Provider Demographics
NPI:1154562767
Name:COOPER, DALLAS MICHELLE (BSW, PSRS)
Entity type:Individual
Prefix:MRS
First Name:DALLAS
Middle Name:MICHELLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:BSW, PSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 218
Mailing Address - Street 2:
Mailing Address - City:BOLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74829
Mailing Address - Country:US
Mailing Address - Phone:918-667-3367
Mailing Address - Fax:
Practice Address - Street 1:RR 1, BOX 35D
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829
Practice Address - Country:US
Practice Address - Phone:918-667-3367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100685660AMedicaid
OK100685660DMedicaid