Provider Demographics
NPI:1598382913
Name:COOKE, KRISTEN MICHELLE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:COOKE
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 1:1935 TALON DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3852
Mailing Address - Country:US
Mailing Address - Phone:630-200-0175
Mailing Address - Fax:
Practice Address - Street 1:1938 E LINCOLN HWY UNIT 219
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-3860
Practice Address - Country:US
Practice Address - Phone:815-320-3749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490164841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical