Provider Demographics
NPI:1205299237
Name:COOK, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
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 1:5065 GATESHEAD ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20300 SUPERIOR RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6331
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010983991041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1205299237Medicaid