Basic Information
| Provider Information | |||||||||
| NPI: | 1669785200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | L.C.S.W., C.C.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 E OCEAN BLVD APT 501 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908025009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606417160 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5901 E 7TH ST BLDG 128 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908225201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628268000 | ||||||||
| FaxNumber: | 5628265270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2010 | ||||||||
| LastUpdateDate: | 07/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 18135 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.