Provider Demographics
NPI:1821524380
Name:COOK, MARTIN A SR (LMSW)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
Last Name:COOK
Suffix:SR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 ARENAS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ARENAS VALLEY
Mailing Address - State:NM
Mailing Address - Zip Code:88022-9723
Mailing Address - Country:US
Mailing Address - Phone:575-654-7118
Mailing Address - Fax:
Practice Address - Street 1:66 ARENAS VALLEY RD
Practice Address - Street 2:
Practice Address - City:ARENAS VALLEY
Practice Address - State:NM
Practice Address - Zip Code:88022-9723
Practice Address - Country:US
Practice Address - Phone:575-654-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NMM-10244104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician