Provider Demographics
NPI:1447740527
Name:COOKE, SHASTA TOBI
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:TOBI
Last Name:COOKE
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 1:677 HALF W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402
Mailing Address - Country:US
Mailing Address - Phone:530-356-0655
Mailing Address - Fax:
Practice Address - Street 1:677 1/2 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402
Practice Address - Country:US
Practice Address - Phone:530-356-0655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY3753896OtherGOV