Provider Demographics
NPI:1780455097
Name:COOK, ALYSSA MARIAN (MS)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIAN
Last Name:COOK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10135 IRONGATE DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-7920
Mailing Address - Country:US
Mailing Address - Phone:208-509-3773
Mailing Address - Fax:
Practice Address - Street 1:1014 W HEMINGWAY BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1733
Practice Address - Country:US
Practice Address - Phone:208-991-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-10124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health