Provider Demographics
NPI:1215578372
Name:COOK, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
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:PO BOX 8344
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-0344
Mailing Address - Country:US
Mailing Address - Phone:509-995-3388
Mailing Address - Fax:509-321-4350
Practice Address - Street 1:1209 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-4101
Practice Address - Country:US
Practice Address - Phone:509-995-3388
Practice Address - Fax:509-321-4350
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2024-05-03
Deactivation Date:2022-01-17
Deactivation Code:
Reactivation Date:2024-05-03
Provider Licenses
StateLicense IDTaxonomies
WACB60995669106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2100815Medicaid