Healthcare Provider Details

I. General information

NPI: 1851571939
Provider Name (Legal Business Name): CONNIE COOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 B ST SUITE 1570
SAN DIEGO CA
92101-4520
US

IV. Provider business mailing address

600 B ST SUITE 1570
SAN DIEGO CA
92101-4520
US

V. Phone/Fax

Practice location:
  • Phone: 619-615-0439
  • Fax: 619-615-3197
Mailing address:
  • Phone: 619-615-0439
  • Fax: 619-615-3197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number23662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: