Provider Demographics
NPI:1700890258
Name:COOK, CAROLYN LACY (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:LACY
Last Name:COOK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 W BROADWAY STE 201
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1828
Mailing Address - Country:US
Mailing Address - Phone:608-223-1506
Mailing Address - Fax:
Practice Address - Street 1:1532 W BROADWAY STE 201
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53713-1828
Practice Address - Country:US
Practice Address - Phone:608-223-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5639-125103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling