Provider Demographics
NPI:1063003242
Name:COOK, ANDREA DANIELLE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DANIELLE
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 64 BOX 4683
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764-9408
Mailing Address - Country:US
Mailing Address - Phone:573-238-1300
Mailing Address - Fax:573-238-1302
Practice Address - Street 1:HC 64 BOX 4683
Practice Address - Street 2:
Practice Address - City:MARBLE HILL
Practice Address - State:MO
Practice Address - Zip Code:63764-9408
Practice Address - Country:US
Practice Address - Phone:573-238-1300
Practice Address - Fax:573-238-1302
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness