Provider Demographics
NPI:1427114339
Name:COOK, KATHLEEN ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:COOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60422 CROWN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-5186
Mailing Address - Country:US
Mailing Address - Phone:574-299-0825
Mailing Address - Fax:
Practice Address - Street 1:1817 MIAMI ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46613-2821
Practice Address - Country:US
Practice Address - Phone:574-234-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002108A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34002108AOtherSOCIAL WORK LICENSE