Provider Demographics
NPI:1528592771
Name:COOK, ETHAN GREGORY
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:GREGORY
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 1:5729 NANCY DR SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418
Mailing Address - Country:US
Mailing Address - Phone:616-206-6654
Mailing Address - Fax:
Practice Address - Street 1:5729 NANCY DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-9789
Practice Address - Country:US
Practice Address - Phone:616-206-6654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker