Provider Demographics
NPI:1629384573
Name:COOK, PATTY LORRAINE (MSW, LISW)
Entity Type:Individual
Prefix:MRS
First Name:PATTY
Middle Name:LORRAINE
Last Name:COOK
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5351
Mailing Address - Country:US
Mailing Address - Phone:309-779-2800
Mailing Address - Fax:
Practice Address - Street 1:2701 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5351
Practice Address - Country:US
Practice Address - Phone:309-779-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-28
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0069691041C0700X
IL1490146071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208833012OtherMEDICARE PTAN