Basic Information
| Provider Information | |||||||||
| NPI: | 1366939936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | DONNY | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CADC INTERN, 01592-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 S PRATT AVE | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897014730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758823945 | ||||||||
| FaxNumber: | 7758826126 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 S PRATT AVE | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897014730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758823945 | ||||||||
| FaxNumber: | 7758826126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2018 | ||||||||
| LastUpdateDate: | 04/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 01592-I | NV | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1023253267 | 05 | NV | MEDICAID |