Provider Demographics
NPI:1093477457
Name:COOK, DYLAN
Entity Type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 BLACK LAKE BLVD SW APT II8
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-5704
Mailing Address - Country:US
Mailing Address - Phone:360-481-9642
Mailing Address - Fax:
Practice Address - Street 1:1017 4TH AVE E
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4016
Practice Address - Country:US
Practice Address - Phone:360-539-7726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61094609225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty