Basic Information
| Provider Information | |||||||||
| NPI: | 1821462417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | DEONA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BS, LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 956 | ||||||||
| Address2: | |||||||||
| City: | MOUNDRIDGE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671070956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6208601904 | ||||||||
| FaxNumber: | 6203454684 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S AVE B | ||||||||
| Address2: | |||||||||
| City: | MOUNDRIDGE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6208601904 | ||||||||
| FaxNumber: | 6203454684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2015 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 394 | KS | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.