Basic Information
| Provider Information | |||||||||
| NPI: | 1962659425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19871 ALBANY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480753982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136224167 | ||||||||
| FaxNumber: | 3138930064 | ||||||||
| Practice Location | |||||||||
| Address1: | 19871 ALBANY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480753982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136224167 | ||||||||
| FaxNumber: | 3138930064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2008 | ||||||||
| LastUpdateDate: | 08/26/2008 | ||||||||
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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 | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 3434247 | 05 | MI | MEDICAID |