Basic Information
| Provider Information | |||||||||
| NPI: | 1235726951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKMAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 628 9TH AVE S | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582014862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012401092 | ||||||||
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| Practice Location | |||||||||
| Address1: | 323 S MINNESOTA ST | ||||||||
| Address2: | |||||||||
| City: | CROOKSTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567161601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182819200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2020 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 305109 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.