Provider Demographics
NPI:1942361605
Name:COOPER, LISA (LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E OLIVE ST
Mailing Address - Street 2:SOUND MENTAL HEALTH
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2735
Mailing Address - Country:US
Mailing Address - Phone:206-302-2200
Mailing Address - Fax:206-302-2210
Practice Address - Street 1:6100 SOUTHCENTER BLVD
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2441
Practice Address - Country:US
Practice Address - Phone:206-444-7930
Practice Address - Fax:206-444-7910
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000063251041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R33808Medicare UPIN
AB34480Medicare ID - Type Unspecified