Provider Demographics
NPI:1316281801
Name:COOK, KENNETH J (OTA/L)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:COOK
Suffix:
Gender:M
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3746 N TIPTON PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6309
Mailing Address - Country:US
Mailing Address - Phone:208-484-5050
Mailing Address - Fax:
Practice Address - Street 1:8211 W USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5756
Practice Address - Country:US
Practice Address - Phone:208-375-3700
Practice Address - Fax:208-375-3760
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-098224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant