Provider Demographics
NPI:1154030872
Name:COOK, MINIIMAH EVELEENA ADA
Entity type:Individual
Prefix:MS
First Name:MINIIMAH
Middle Name:EVELEENA ADA
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 1:664 INDIGO LN NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-6048
Mailing Address - Country:US
Mailing Address - Phone:415-235-4736
Mailing Address - Fax:
Practice Address - Street 1:2711 IRVIN WAY STE 201
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1724
Practice Address - Country:US
Practice Address - Phone:888-739-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty