Provider Demographics
NPI:1053913087
Name:COOPER, SHATRISSE MARKITA
Entity type:Individual
Prefix:
First Name:SHATRISSE
Middle Name:MARKITA
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 1:10710 GUY R BREWER BLVD UNIT 9C
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-2388
Mailing Address - Country:US
Mailing Address - Phone:646-708-3034
Mailing Address - Fax:
Practice Address - Street 1:10710 GUY R BREWER BLVD UNIT 9C
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-2388
Practice Address - Country:US
Practice Address - Phone:646-708-3034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109526104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker