Provider Demographics
NPI:1194525626
Name:COOK, MICHAEL ALLEN (LAC-23402)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:COOK
Suffix:
Gender:
Credentials:LAC-23402
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-2115
Mailing Address - Country:US
Mailing Address - Phone:907-209-0829
Mailing Address - Fax:
Practice Address - Street 1:6602 E CARONDELET DR # 85710
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2119
Practice Address - Country:US
Practice Address - Phone:520-524-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
AZLAC-23402101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health