Provider Demographics
NPI:1386219723
Name:CENTERS COOKE, MALISSA ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:ELIZABETH
Last Name:CENTERS COOKE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-7813
Mailing Address - Country:US
Mailing Address - Phone:270-237-7401
Mailing Address - Fax:
Practice Address - Street 1:100 HICKORY LN
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42164-7813
Practice Address - Country:US
Practice Address - Phone:270-237-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY168678235Z00000X
KY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist