Provider Demographics
NPI:1174848774
Name:COOK, CARISSA
Entity Type:Individual
Prefix:
First Name:CARISSA
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 1:3200 MAIN ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4725
Mailing Address - Country:US
Mailing Address - Phone:304-748-3768
Mailing Address - Fax:
Practice Address - Street 1:3200 MAIN ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4725
Practice Address - Country:US
Practice Address - Phone:304-748-3768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health