Provider Demographics
NPI:1063813293
Name:COOK, KRISTINE (LSW)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12557 RAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9009
Mailing Address - Country:US
Mailing Address - Phone:440-283-5686
Mailing Address - Fax:440-285-4552
Practice Address - Street 1:12557 RAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9009
Practice Address - Country:US
Practice Address - Phone:440-283-5686
Practice Address - Fax:440-285-4552
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS. 0800091104100000X
OHI.22033941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker