Basic Information
| Provider Information | |||||||||
| NPI: | 1831288836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKE | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | KARIN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, MSW, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5845 WESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484399459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8105130040 | ||||||||
| FaxNumber: | 2486053525 | ||||||||
| Practice Location | |||||||||
| Address1: | 8341 OFFICE PARK DR | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484392077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8105130040 | ||||||||
| FaxNumber: | 2486053525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801034449 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1068400 | 01 | MI | BLUE CARE NETWORK | OTHER | 0995653 | 01 | MI | HEALTH PLUS PROVIDER # | OTHER |