Provider Demographics
NPI:1760155196
Name:COOK, OLIVIA JUNE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JUNE
Last Name:COOK
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 LATHROP ST STE 123
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-455-4401
Practice Address - Fax:907-455-4402
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR64019OtherOREGON BOARD OF PHYSICAL THERAPY LICENSE NUMBER