Provider Demographics
NPI:1003640368
Name:COOK, LORA
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:
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 1:17195 PREVOST ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3552
Mailing Address - Country:US
Mailing Address - Phone:313-433-1054
Mailing Address - Fax:
Practice Address - Street 1:17195 PREVOST ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3552
Practice Address - Country:US
Practice Address - Phone:313-433-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty