Provider Demographics
NPI:1972803500
Name:COOK, EDWARD CLEARY JR (PT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:CLEARY
Last Name:COOK
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6029 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25117 SW PARKWAY AVE
Practice Address - Street 2:SUITE D
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:503-570-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist