Provider Demographics
NPI:1255799920
Name:COOK, LEISA KEISHA (LPC-A, LCAS-A)
Entity type:Individual
Prefix:
First Name:LEISA
Middle Name:KEISHA
Last Name:COOK
Suffix:
Gender:F
Credentials:LPC-A, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 GROVER PL
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:NC
Mailing Address - Zip Code:28326-6210
Mailing Address - Country:US
Mailing Address - Phone:910-824-3865
Mailing Address - Fax:
Practice Address - Street 1:75 GROVER PL
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326-6210
Practice Address - Country:US
Practice Address - Phone:910-824-3865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS22226101YA0400X
NCA11962101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)