Basic Information
| Provider Information | |||||||||
| NPI: | 1205299237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | CRYSTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5065 GATESHEAD ST | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482362170 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20300 SUPERIOR RD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481806331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2016 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801098399 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1205299237 | 05 | MI | MEDICAID |