Provider Demographics
NPI:1962611228
Name:COOKE, SHARON FLORA (LISW)
Entity type:Individual
Prefix:MS
First Name:SHARON
Middle Name:FLORA
Last Name:COOKE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8475 FOOTHILLS DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-0977
Mailing Address - Country:US
Mailing Address - Phone:505-634-3628
Mailing Address - Fax:505-634-3675
Practice Address - Street 1:310 W SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-5844
Practice Address - Country:US
Practice Address - Phone:505-634-3628
Practice Address - Fax:505-634-3675
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-39961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z0886Medicaid