Provider Demographics
NPI:1699092809
Name:COOK-VAUGHN, KIMBERLEY LEE (LADC #624)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:LEE
Last Name:COOK-VAUGHN
Suffix:
Gender:F
Credentials:LADC #624
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5459
Mailing Address - Country:US
Mailing Address - Phone:918-431-0634
Mailing Address - Fax:918-431-0654
Practice Address - Street 1:2511 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5459
Practice Address - Country:US
Practice Address - Phone:918-431-0634
Practice Address - Fax:918-431-0654
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK624101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor