Provider Demographics
NPI:1497859557
Name:COOK, RUBY BROADBUS
Entity Type:Individual
Prefix:MRS
First Name:RUBY
Middle Name:BROADBUS
Last Name:COOK
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 1:3009 EDGEWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230
Mailing Address - Country:US
Mailing Address - Phone:804-321-7240
Mailing Address - Fax:
Practice Address - Street 1:3113 W MARSHALL STREET SUITE 1C
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230
Practice Address - Country:US
Practice Address - Phone:804-377-3955
Practice Address - Fax:804-377-3956
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710000849101YA0400X
VA0701002780101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0054100501Medicaid