Provider Demographics
NPI:1093805194
Name:COOKE, PRISCILLA D (MSW, LCSW, LCAS)
Entity Type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:D
Last Name:COOKE
Suffix:
Gender:F
Credentials:MSW, LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 POST OAK RD
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8027
Mailing Address - Country:US
Mailing Address - Phone:336-993-1859
Mailing Address - Fax:
Practice Address - Street 1:119 WEST AVE
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081-4332
Practice Address - Country:US
Practice Address - Phone:704-630-6634
Practice Address - Fax:866-828-5520
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0026921041C0700X, 101YM0800X
NC1369101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003167Medicaid