Provider Demographics
NPI:1447998208
Name:COOKE, KRISTIN (MA,CC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:COOKE
Suffix:
Gender:F
Credentials:MA,CC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7432 EWING AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-8642
Mailing Address - Country:US
Mailing Address - Phone:318-537-0124
Mailing Address - Fax:
Practice Address - Street 1:4865 BRIARHAVEN RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4600
Practice Address - Country:US
Practice Address - Phone:817-814-6926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109161235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659249401Medicaid