Provider Demographics
NPI:1154681690
Name:COOK, BRUCE CONRAD (LPT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:CONRAD
Last Name:COOK
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18217 HALE AVE
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-3550
Mailing Address - Country:US
Mailing Address - Phone:408-465-8280
Mailing Address - Fax:831-674-2012
Practice Address - Street 1:18217 HALE AVE
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-3550
Practice Address - Country:US
Practice Address - Phone:408-465-8280
Practice Address - Fax:831-674-2012
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALP 19366167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician