Basic Information
| Provider Information | |||||||||
| NPI: | 1235188491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1101 W 40TH ST | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374093101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234860774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1201 S SEMINOLE DR | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374121135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234860774 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904009757 | VA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | CSW007326 | GA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 11609 | MD | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 6757 | TN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | C012712 | NC | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 447380900 | 05 | MD | MEDICAID | 003213184C | 05 | GA | MEDICAID | 215422ZDV | 05 | VA | MEDICAID | Q048467 | 05 | TN | MEDICAID |