Provider Demographics
NPI:1154177301
Name:COOK, SAMANTHA NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:COOK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 FAIROAK LN
Mailing Address - Street 2:
Mailing Address - City:FORDLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65652-8212
Mailing Address - Country:US
Mailing Address - Phone:417-839-2620
Mailing Address - Fax:
Practice Address - Street 1:301 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-5303
Practice Address - Country:US
Practice Address - Phone:417-875-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011017429224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant