Provider Demographics
NPI:1790847135
Name:COOK, KELLY L S (LICSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L S
Last Name:COOK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEA
Other - Last Name:SHEPARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2700 1ST ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4585
Mailing Address - Country:US
Mailing Address - Phone:320-223-0503
Mailing Address - Fax:800-692-2091
Practice Address - Street 1:7401 METRO BLVD STE 250
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-3062
Practice Address - Country:US
Practice Address - Phone:320-403-4013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN175411041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical