Provider Demographics
NPI:1992523138
Name:COOPER, CHARLEY DYLAN (LMSW)
Entity type:Individual
Prefix:
First Name:CHARLEY
Middle Name:DYLAN
Last Name:COOPER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 GREENE AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-1483
Mailing Address - Country:US
Mailing Address - Phone:516-776-5464
Mailing Address - Fax:
Practice Address - Street 1:234 GREENE AVE APT 2R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-1483
Practice Address - Country:US
Practice Address - Phone:516-776-5464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124005104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker