Basic Information
| Provider Information | |||||||||
| NPI: | 1659430858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | LYNDA | ||||||||
| MiddleName: | MANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 355 | ||||||||
| Address2: | |||||||||
| City: | WENTWORTH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363428316 | ||||||||
| FaxNumber: | 3363428352 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 NC 65 | ||||||||
| Address2: | |||||||||
| City: | WENTWORTH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273750355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363428316 | ||||||||
| FaxNumber: | 3363428352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 6111832 | 05 | NC | MEDICAID |