Provider Demographics
NPI:1467297168
Name:COOPER, SIDDIQAH T
Entity type:Individual
Prefix:
First Name:SIDDIQAH
Middle Name:T
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 PRESTIGIOUS LN APT E
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-9636
Mailing Address - Country:US
Mailing Address - Phone:704-208-8438
Mailing Address - Fax:
Practice Address - Street 1:2309 PRESTIGIOUS LN APT E
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-9636
Practice Address - Country:US
Practice Address - Phone:704-208-8438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist