Provider Demographics
NPI:1841693835
Name:COOPER, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
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 1:426 WESTPORT AVE # 1016
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-4423
Mailing Address - Country:US
Mailing Address - Phone:917-719-4761
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVENUE
Practice Address - Street 2:SUITE 704 - 3051
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5208
Practice Address - Country:US
Practice Address - Phone:917-719-4761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095467104100000X
NY0870921041C0700X
CT118881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker