Provider Demographics
NPI:1205469251
Name:COOK, KRYSTALLIA NICOLE
Entity type:Individual
Prefix:MRS
First Name:KRYSTALLIA
Middle Name:NICOLE
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 1:2231 HILLSDALE DR
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-5233
Mailing Address - Country:US
Mailing Address - Phone:803-292-6314
Mailing Address - Fax:
Practice Address - Street 1:2228 WOODSIDE EXECUTIVE CT
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-3812
Practice Address - Country:US
Practice Address - Phone:803-470-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional