Provider Demographics
NPI:1265556047
Name:COOKWATERS, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:COOKWATERS
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:PO BOX 374
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-0374
Mailing Address - Country:US
Mailing Address - Phone:302-731-1504
Mailing Address - Fax:302-731-2720
Practice Address - Street 1:254 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7311
Practice Address - Country:US
Practice Address - Phone:302-731-1405
Practice Address - Fax:302-731-2720
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE251101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)