Provider Demographics
NPI:1760704910
Name:COOK, ALICIA L (SAC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:L
Last Name:COOK
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-454-4101
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:902 RIVERSIDE DR STE 204
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1992
Practice Address - Country:US
Practice Address - Phone:920-720-2300
Practice Address - Fax:920-720-3719
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15837101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760704910Medicaid