Provider Demographics
NPI:1528338415
Name:COOK, PHYLLIS IRENE (PLPC)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:IRENE
Last Name:COOK
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:MISS
Other - First Name:PHYLLIS
Other - Middle Name:IRENE
Other - Last Name:NASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 1068
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:MO
Mailing Address - Zip Code:65668-9715
Mailing Address - Country:US
Mailing Address - Phone:417-399-6504
Mailing Address - Fax:
Practice Address - Street 1:707 S PEARL AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-4334
Practice Address - Country:US
Practice Address - Phone:417-718-4552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011039291101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional