Provider Demographics
NPI:1821593583
Name:COOK, MARY (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 PREMIER DR STE 234
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2693
Mailing Address - Country:US
Mailing Address - Phone:916-765-2208
Mailing Address - Fax:
Practice Address - Street 1:7200 DENTON HWY
Practice Address - Street 2:
Practice Address - City:WATAUGA
Practice Address - State:TX
Practice Address - Zip Code:76148-1202
Practice Address - Country:US
Practice Address - Phone:817-691-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-18-29300103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1-17-29300OtherBACB