Provider Demographics
NPI:1245416940
Name:COOK, KENNETH W (BS, CAC-1)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:COOK
Suffix:
Gender:M
Credentials:BS, CAC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:VASSAR
Mailing Address - State:MI
Mailing Address - Zip Code:48768-9584
Mailing Address - Country:US
Mailing Address - Phone:989-823-7640
Mailing Address - Fax:989-823-8394
Practice Address - Street 1:150 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:VASSAR
Practice Address - State:MI
Practice Address - Zip Code:48768-9584
Practice Address - Country:US
Practice Address - Phone:989-823-7640
Practice Address - Fax:989-823-8394
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-04245104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker