Provider Demographics
NPI:1063543528
Name:CANDICE COOK, LLC
Entity type:Organization
Organization Name:CANDICE COOK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:757-675-1720
Mailing Address - Street 1:236 MUSTANG TRL STE 202
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7517
Mailing Address - Country:US
Mailing Address - Phone:757-675-1720
Mailing Address - Fax:757-306-4994
Practice Address - Street 1:236 MUSTANG TRL STE 202
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7517
Practice Address - Country:US
Practice Address - Phone:757-675-1720
Practice Address - Fax:757-306-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002189101YP2500X
VA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty