Provider Demographics
NPI:1932742350
Name:COOK, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 SYLVESTER RD UNIT KK1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3587
Mailing Address - Country:US
Mailing Address - Phone:863-510-1476
Mailing Address - Fax:
Practice Address - Street 1:31918 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3730
Practice Address - Country:US
Practice Address - Phone:727-207-0508
Practice Address - Fax:727-491-5182
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101264300Medicaid