Basic Information
| Provider Information | |||||||||
| NPI: | 1124573746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 867 | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845010867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377200 | ||||||||
| FaxNumber: | 4356372377 | ||||||||
| Practice Location | |||||||||
| Address1: | 198 EAST CENTER STREET | ||||||||
| Address2: | |||||||||
| City: | MOAB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845320000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352596131 | ||||||||
| FaxNumber: | 4352595369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2016 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 10294304-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.