Provider Demographics
NPI:1568609618
Name:COOK, DESTINY DAWN (MT)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:DAWN
Last Name:COOK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-1921
Mailing Address - Country:US
Mailing Address - Phone:207-620-4103
Mailing Address - Fax:
Practice Address - Street 1:186 MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-1921
Practice Address - Country:US
Practice Address - Phone:207-620-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT3911225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist