Provider Demographics
NPI:1669785200
Name:COOK, TERRY CLARK (LCSW, CCM)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:CLARK
Last Name:COOK
Suffix:
Gender:M
Credentials:LCSW, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E OCEAN BLVD APT 501
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5009
Mailing Address - Country:US
Mailing Address - Phone:760-641-7160
Mailing Address - Fax:
Practice Address - Street 1:5901 E 7TH ST BLDG 128
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90822-5201
Practice Address - Country:US
Practice Address - Phone:562-826-8000
Practice Address - Fax:562-826-5270
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA181351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical