Provider Demographics
NPI:1427197367
Name:COOK, TANYA ILENE (EDS)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:ILENE
Last Name:COOK
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:WV
Mailing Address - Zip Code:24801-2710
Mailing Address - Country:US
Mailing Address - Phone:304-549-8100
Mailing Address - Fax:
Practice Address - Street 1:30 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:WV
Practice Address - Zip Code:24801-2008
Practice Address - Country:US
Practice Address - Phone:304-436-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21035103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9201036000Medicaid