Provider Demographics
NPI:1093174765
Name:COOK, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
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 1:17969 WILSON SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-8588
Mailing Address - Country:US
Mailing Address - Phone:608-538-3781
Mailing Address - Fax:608-538-3782
Practice Address - Street 1:12489 STATE HIGHWAY 56
Practice Address - Street 2:
Practice Address - City:VIOLA
Practice Address - State:WI
Practice Address - Zip Code:54664-8914
Practice Address - Country:US
Practice Address - Phone:608-538-3781
Practice Address - Fax:608-538-3782
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities