Provider Demographics
NPI:1477293272
Name:COOK, CAROLYN MARIE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:COOK
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 BELLPORT AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2219
Mailing Address - Country:US
Mailing Address - Phone:631-741-0143
Mailing Address - Fax:
Practice Address - Street 1:861 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1613
Practice Address - Country:US
Practice Address - Phone:631-472-1005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009231-1225700000X
NY009231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009231OtherNYSHIP