Basic Information
| Provider Information | |||||||||
| NPI: | 1295222131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOPERMAN | ||||||||
| FirstName: | MARISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2580 LIN DO CT | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291501832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039054427 | ||||||||
| FaxNumber: | 8039054431 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 W 9TH AVE STE BANDC | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194061209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108311865 | ||||||||
| FaxNumber: | 8039054431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | BH003545 | PA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.