Provider Demographics
NPI:1548770415
Name:COOK, ELLISE KATHRYN (LSW)
Entity Type:Individual
Prefix:
First Name:ELLISE
Middle Name:KATHRYN
Last Name:COOK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7384 TIMBERKNOLL DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7533
Mailing Address - Country:US
Mailing Address - Phone:513-509-7029
Mailing Address - Fax:
Practice Address - Street 1:3296 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-1003
Practice Address - Country:US
Practice Address - Phone:513-409-3635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1802959104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker