Provider Demographics
NPI:1619904752
Name:COOK, DEBORAH (PT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5005
Mailing Address - Country:US
Mailing Address - Phone:843-685-4981
Mailing Address - Fax:
Practice Address - Street 1:3675 SPRUCE DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5005
Practice Address - Country:US
Practice Address - Phone:843-685-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2399174400000X
MEMT39174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME007016OtherBLUE CROSS BLUE SHIELD
MEMN4071OtherHARVARD PILGRIM
ME7966435OtherCIGNA HEALTHCARE
MEMM8707Medicare ID - Type UnspecifiedPROVIDER ID