Provider Demographics
NPI:1023283520
Name:COOK, STEPHEN BRADLEY (MED)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:BRADLEY
Last Name:COOK
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 WISE RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-5521
Mailing Address - Country:US
Mailing Address - Phone:843-365-8884
Mailing Address - Fax:
Practice Address - Street 1:2404 WISE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5521
Practice Address - Country:US
Practice Address - Phone:843-365-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0601472101YS0200X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty