Healthcare Provider Details

I. General information

NPI: 1265917298
Provider Name (Legal Business Name): CARLY NICOLE COOK MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY NICOLE FORMAN

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

IV. Provider business mailing address

12120 IVY LN
AUBURN CA
95603-3449
US

V. Phone/Fax

Practice location:
  • Phone: 916-843-7000
  • Fax:
Mailing address:
  • Phone: 530-308-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: