Provider Demographics
NPI:1215258454
Name:COOK, BETHANY (MA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 E JANATA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5317
Mailing Address - Country:US
Mailing Address - Phone:630-424-8900
Mailing Address - Fax:
Practice Address - Street 1:3903 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2555
Practice Address - Country:US
Practice Address - Phone:219-392-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008237103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical