Provider Demographics
NPI:1295777183
Name:COOK, KENNETH BRUCE (LCSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:BRUCE
Last Name:COOK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 CONCORD RD SE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-5306
Mailing Address - Country:US
Mailing Address - Phone:770-436-1879
Mailing Address - Fax:770-434-3005
Practice Address - Street 1:1260 CONCORD RD SE
Practice Address - Street 2:SUITE 202
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-5306
Practice Address - Country:US
Practice Address - Phone:770-436-1879
Practice Address - Fax:770-434-3005
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0002921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW000292OtherLICENSED CLINICAL SOCIAL