Provider Demographics
NPI:1265022651
Name:COOK-DAVIS, CAITLIN DENISE
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:DENISE
Last Name:COOK-DAVIS
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 1:100 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0510
Mailing Address - Country:US
Mailing Address - Phone:209-523-4573
Mailing Address - Fax:
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4308
Practice Address - Country:US
Practice Address - Phone:209-550-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2024-04-03
Deactivation Date:2024-02-02
Deactivation Code:
Reactivation Date:2024-02-15
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician