Provider Demographics
NPI:1063796654
Name:COOK, MYLENE (LCSW)
Entity type:Individual
Prefix:
First Name:MYLENE
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2423
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-2423
Mailing Address - Country:US
Mailing Address - Phone:800-464-4000
Mailing Address - Fax:
Practice Address - Street 1:393 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91188-9417
Practice Address - Country:US
Practice Address - Phone:800-464-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-01
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS223711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical