Provider Demographics
NPI:1306203880
Name:COOKE, VICKIE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:COOKE
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:PO BOX 3394
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-0394
Mailing Address - Country:US
Mailing Address - Phone:443-629-0646
Mailing Address - Fax:
Practice Address - Street 1:3806 RAVENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-2022
Practice Address - Country:US
Practice Address - Phone:443-629-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC1812171M00000X
MDLCA3165101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDSC1812OtherDEPARTMENT OF HEALTH AND MENTAL HYGIENE