Healthcare Provider Details

I. General information

NPI: 1861379331
Provider Name (Legal Business Name): TYRELL COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 CHESTNUT AVE
LONG BEACH CA
90813-1674
US

IV. Provider business mailing address

43736 32ND ST E
LANCASTER CA
93535-6217
US

V. Phone/Fax

Practice location:
  • Phone: 562-599-8444
  • Fax: 562-591-6134
Mailing address:
  • Phone: 323-270-3595
  • Fax: 562-591-6134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1418350924
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: