Provider Demographics
NPI:1386007102
Name:COOK, DEREK (LAT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:SWEENY
Mailing Address - State:TX
Mailing Address - Zip Code:77480-1308
Mailing Address - Country:US
Mailing Address - Phone:979-491-8159
Mailing Address - Fax:979-491-8187
Practice Address - Street 1:1310 N ELM ST
Practice Address - Street 2:
Practice Address - City:SWEENY
Practice Address - State:TX
Practice Address - Zip Code:77480-1308
Practice Address - Country:US
Practice Address - Phone:979-491-8159
Practice Address - Fax:979-491-8187
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT23962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer