Provider Demographics
NPI:1265917298
Name:COOK, CARLY NICOLE (MSW)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:NICOLE
Last Name:COOK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:NICOLE
Other - Last Name:FORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12120 IVY LN
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-3449
Mailing Address - Country:US
Mailing Address - Phone:530-308-6575
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-843-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker