Provider Demographics
NPI:1821462417
Name:COOK, DEONA (BS, LAC)
Entity Type:Individual
Prefix:
First Name:DEONA
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:BS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 956
Mailing Address - Street 2:
Mailing Address - City:MOUNDRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67107-0956
Mailing Address - Country:US
Mailing Address - Phone:620-860-1904
Mailing Address - Fax:620-345-4684
Practice Address - Street 1:200 S AVE B
Practice Address - Street 2:
Practice Address - City:MOUNDRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67107
Practice Address - Country:US
Practice Address - Phone:620-860-1904
Practice Address - Fax:620-345-4684
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS394101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)