Provider Demographics
NPI:1790482693
Name:COOKE, ELIZABETH GRACE (BS, BIS, CS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:COOKE
Suffix:
Gender:F
Credentials:BS, BIS, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 ALDER AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5815
Mailing Address - Country:US
Mailing Address - Phone:208-503-9104
Mailing Address - Fax:
Practice Address - Street 1:1519 ALDER AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5815
Practice Address - Country:US
Practice Address - Phone:208-503-9104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID222Q00000XMedicaid