Provider Demographics
NPI:1821581091
Name:COOK, SAMANTHA LEIGH
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:LEIGH
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 1:26640 BERG RD APT 1707
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-5385
Mailing Address - Country:US
Mailing Address - Phone:219-204-2261
Mailing Address - Fax:
Practice Address - Street 1:835 MASON ST STE B220
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2262
Practice Address - Country:US
Practice Address - Phone:313-561-9064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016917103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth