Basic Information
Provider Information
NPI: 1003002684
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COOK
FirstName: CARRIE
MiddleName: E
NamePrefix:  
NameSuffix:  
Credential: LISW-S
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3095 KETTERING BLVD
Address2:  
City: MORAINE
State: OH
PostalCode: 454391983
CountryCode: US
TelephoneNumber: 9375341369
FaxNumber:  
Practice Location
Address1: 713 W GRAND AVE
Address2:  
City: DAYTON
State: OH
PostalCode: 454065327
CountryCode: US
TelephoneNumber: 9377190255
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/18/2007
LastUpdateDate: 03/24/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XI.1501349-SUPVOHY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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