Provider Demographics
NPI:1669168696
Name:COOKE, SAMUEL BERNELL
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:BERNELL
Last Name:COOKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 STEGALL LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-9724
Mailing Address - Country:US
Mailing Address - Phone:803-448-1747
Mailing Address - Fax:
Practice Address - Street 1:142 TANGLEWOOD CV
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-7783
Practice Address - Country:US
Practice Address - Phone:803-448-1747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health