Provider Demographics
NPI:1871093013
Name:COOK, TARA (BCBA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CULLODEN CT
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-7205
Mailing Address - Country:US
Mailing Address - Phone:334-258-0888
Mailing Address - Fax:
Practice Address - Street 1:256 HONEYSUCKLE RD STE 6
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1168
Practice Address - Country:US
Practice Address - Phone:334-792-5020
Practice Address - Fax:334-460-8468
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-20-43478103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-43478OtherBACB