Provider Demographics
NPI:1841750106
Name:COOK, MILISSA (RBT)
Entity Type:Individual
Prefix:
First Name:MILISSA
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 14TH ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4059
Mailing Address - Country:US
Mailing Address - Phone:800-503-4150
Mailing Address - Fax:
Practice Address - Street 1:515 W 14TH ST UNIT D
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4059
Practice Address - Country:US
Practice Address - Phone:800-503-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC200603778678OtherDRIVER'S LICENSE