Provider Demographics
NPI:1467110247
Name:COOK, SHANE L
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:L
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 S GINGER ST
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-7212
Mailing Address - Country:US
Mailing Address - Phone:971-261-8407
Mailing Address - Fax:
Practice Address - Street 1:8915 SW CENTER ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6307
Practice Address - Country:US
Practice Address - Phone:503-726-3706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health