Provider Demographics
NPI:1932512373
Name:COOK, MICHELLE MARIE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
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 1:6248 BIRDCAGE ST
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-5949
Mailing Address - Country:US
Mailing Address - Phone:951-694-0695
Mailing Address - Fax:951-695-6215
Practice Address - Street 1:29748 RANCHO CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5286
Practice Address - Country:US
Practice Address - Phone:951-694-0695
Practice Address - Fax:951-695-6215
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99275106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist