Basic Information
| Provider Information | |||||||||
| NPI: | 1972666832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | MILES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1271 DUBLIN DR | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530279763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622240900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 CAMELOT DR | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549358049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209078201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3948-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39223900 | 05 | WI | MEDICAID |