Provider Demographics
NPI:1528591153
Name:COOK, NANCY ILLBACK (PHD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ILLBACK
Last Name:COOK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 BISSONNET ST
Mailing Address - Street 2:SUITE 335
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-3120
Mailing Address - Country:US
Mailing Address - Phone:713-666-6898
Mailing Address - Fax:
Practice Address - Street 1:4500 BISSONNET ST
Practice Address - Street 2:SUITE 335
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3120
Practice Address - Country:US
Practice Address - Phone:713-666-6898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24908103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist