Basic Information
Provider Information | |||||||||
NPI: | 1003912536 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOK | ||||||||
FirstName: | BARBARA | ||||||||
MiddleName: | LIESBETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1115 BOULDERS PKWY STE 200 | ||||||||
Address2: |   | ||||||||
City: | NORTH CHESTERFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 232254067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045605595 | ||||||||
FaxNumber: | 8045609029 | ||||||||
Practice Location | |||||||||
Address1: | 8501 HARCOURT RD | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462602046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178759105 | ||||||||
FaxNumber: | 3178758638 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 06/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31004275A | IN | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225XH1200X | 31004275A | IN | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | 0119006629 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 200809530 | 05 | IN |   | MEDICAID | 000000388066 | 01 |   | ANTHEM HEALTH PLAN | OTHER |