Provider Demographics
NPI:1023043569
Name:COOK, EDWARD C (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:C
Last Name:COOK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 CENTER STREET
Mailing Address - Street 2:SUITE 8A
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906
Mailing Address - Country:US
Mailing Address - Phone:517-853-1925
Mailing Address - Fax:517-853-1926
Practice Address - Street 1:809 CENTER STREET
Practice Address - Street 2:SUITE 8A
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-5257
Practice Address - Country:US
Practice Address - Phone:517-853-1925
Practice Address - Fax:517-853-1926
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005619103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON111300001Medicare UPIN