Provider Demographics
NPI:1679972343
Name:COOKSON, GWENEVERE JEAN (PT)
Entity Type:Individual
Prefix:
First Name:GWENEVERE
Middle Name:JEAN
Last Name:COOKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GWENEVERE
Other - Middle Name:JEAN
Other - Last Name:MADDOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:91 CAMDEN ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2455
Mailing Address - Country:US
Mailing Address - Phone:207-593-6682
Mailing Address - Fax:207-213-1075
Practice Address - Street 1:91 CAMDEN ST
Practice Address - Street 2:SUITE 401
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2455
Practice Address - Country:US
Practice Address - Phone:207-593-6682
Practice Address - Fax:207-213-1075
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4252225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist