Basic Information
| Provider Information | |||||||||
| NPI: | 1184283079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | R. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 E BROAD ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432132086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146553345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6400 E BROAD ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432132086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146553345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2019 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1903561 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.