Provider Demographics
NPI:1871061051
Name:COOK, DEBORAH (LICSW)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WALNUT ST. PMB 6732
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28 SARIAH LANE
Practice Address - Street 2:
Practice Address - City:ONSET
Practice Address - State:MA
Practice Address - Zip Code:02558-0222
Practice Address - Country:US
Practice Address - Phone:404-862-3413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA118451-SW-LICSW101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000000OtherI AM PRESENTLY UNEMPLOYED. I AM APPLYING FOR AN NPI TO RENEW MY LICSW LICENSE.