Provider Demographics
NPI:1821769498
Name:COOK, CARLY ALEXIS
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ALEXIS
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 1:1843 RIDGE RD APT 11
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-2638
Mailing Address - Country:US
Mailing Address - Phone:573-366-9222
Mailing Address - Fax:
Practice Address - Street 1:100 MARION PKWY
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:IL
Practice Address - Zip Code:62684
Practice Address - Country:US
Practice Address - Phone:217-744-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant