Healthcare Provider Details

I. General information

NPI: 1972903995
Provider Name (Legal Business Name): DANIEL R COOK LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 E. MITCHELL DR. SUITE 100 & 200
PHOENIX AZ
85012-2330
US

IV. Provider business mailing address

202 E. EARLL DR. SUITE 200
PHOENIX AZ
85012-2647
US

V. Phone/Fax

Practice location:
  • Phone: 602-808-2800
  • Fax: 602-599-5711
Mailing address:
  • Phone: 602-808-2800
  • Fax: 602-599-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10897
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: