Provider Demographics
NPI:1417598772
Name:DECOOK, KELSEA QUINN
Entity Type:Individual
Prefix:
First Name:KELSEA
Middle Name:QUINN
Last Name:DECOOK
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 1:7831 S 156TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-3208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7831 S 156TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68136-3208
Practice Address - Country:US
Practice Address - Phone:515-494-3083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOW199889386OtherAETNA