Provider Demographics
NPI:1386210920
Name:COOK, HAYLEY
Entity Type:Individual
Prefix:
First Name:HAYLEY
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 1:1650 W MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2842
Mailing Address - Country:US
Mailing Address - Phone:352-314-3760
Mailing Address - Fax:352-314-2909
Practice Address - Street 1:2210 CR 528
Practice Address - Street 2:
Practice Address - City:SUMTERVILLE
Practice Address - State:FL
Practice Address - Zip Code:33585-5214
Practice Address - Country:US
Practice Address - Phone:352-314-3760
Practice Address - Fax:352-314-2909
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-113230106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105712400Medicaid