Provider Demographics
NPI:1881703601
Name:COOK CONSULTING & PSYCHOLOGICAL SERVICES,PC
Entity type:Organization
Organization Name:COOK CONSULTING & PSYCHOLOGICAL SERVICES,PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, HSPP
Authorized Official - Phone:260-602-5373
Mailing Address - Street 1:11123 PARKVIEW PLAZA DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1707
Mailing Address - Country:US
Mailing Address - Phone:260-602-5373
Mailing Address - Fax:260-627-8460
Practice Address - Street 1:10228 DONALD AVE
Practice Address - Street 2:
Practice Address - City:LEO
Practice Address - State:IN
Practice Address - Zip Code:46765-9507
Practice Address - Country:US
Practice Address - Phone:260-602-5373
Practice Address - Fax:260-627-8460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042048A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN248350Medicare UPIN