Provider Demographics
NPI:1326616830
Name:COOK, TABITHA
Entity Type:Individual
Prefix:
First Name:TABITHA
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 1:350 FAIRWAY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1834
Mailing Address - Country:US
Mailing Address - Phone:979-541-3481
Mailing Address - Fax:
Practice Address - Street 1:208 W NORRIS ST
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-2916
Practice Address - Country:US
Practice Address - Phone:979-541-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-12
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-21-159475106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician