Provider Demographics
NPI:1780727495
Name:COOK, BETH LESLEY (PHD)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:LESLEY
Last Name:COOK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3505
Mailing Address - Country:US
Mailing Address - Phone:415-666-3516
Mailing Address - Fax:
Practice Address - Street 1:1125 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1418
Practice Address - Country:US
Practice Address - Phone:415-485-3546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18944103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL189440Medicare ID - Type UnspecifiedNEUROPSYCHOLOGIST