Provider Demographics
NPI:1992291447
Name:COOK, TISHAUN CHARMAINE
Entity type:Individual
Prefix:
First Name:TISHAUN
Middle Name:CHARMAINE
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 METROPOLITAN OVAL APT 3C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-6770
Mailing Address - Country:US
Mailing Address - Phone:347-849-5385
Mailing Address - Fax:
Practice Address - Street 1:22 METROPOLITAN OVAL APT 3C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-6770
Practice Address - Country:US
Practice Address - Phone:347-849-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102835-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker