MEDICARE: KATHLEEN ANNE COOK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	34002108A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34002108A	OTHER	IN	SOCIAL WORK LICENSE

General Provider Information

NPI Number	:	1427114339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN ANNE COOK LCSW

Provider Business Mailing Address
First Line	:	60422 CROWN RIDGE DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-5186
Country	:	US
Telephone Number	:	574-299-0825
Fax Number	:

Provider Business Practice Location Address
First Line	:	1817 MIAMI ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46613-2821
Country	:	US
Telephone Number	:	574-234-3111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	01/11/2026

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