Provider Demographics
NPI:1225163231
Name:COOKE, KIMBERLY L (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:COOKE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4517
Mailing Address - Country:US
Mailing Address - Phone:617-390-5532
Mailing Address - Fax:
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:SUITE 5C
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:617-913-0429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1122381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical