Provider Demographics
NPI:1083784516
Name:PALK, MIKE (LPC)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:
Last Name:PALK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2916
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38502-2916
Mailing Address - Country:US
Mailing Address - Phone:931-528-6167
Mailing Address - Fax:931-526-9300
Practice Address - Street 1:377 SHORT ST
Practice Address - Street 2:SUITE D
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-7119
Practice Address - Country:US
Practice Address - Phone:931-528-6167
Practice Address - Fax:931-526-9300
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3148479OtherTN BLUE CROSS BLUE SHIELD