Provider Demographics
NPI:1538641121
Name:COOK, KATHLEEN HARTWAY
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:HARTWAY
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 1:30795 23 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5720
Mailing Address - Country:US
Mailing Address - Phone:586-421-3030
Mailing Address - Fax:586-421-3031
Practice Address - Street 1:30795 23 MILE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-5720
Practice Address - Country:US
Practice Address - Phone:586-421-3030
Practice Address - Fax:586-421-3031
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist