Healthcare Provider Details

I. General information

NPI: 1467811620
Provider Name (Legal Business Name): MS. BREANNA COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27403 YNEZ RD STE 204
TEMECULA CA
92591-4616
US

IV. Provider business mailing address

1050 LA SALLE CIR
CORONA CA
92879-7728
US

V. Phone/Fax

Practice location:
  • Phone: 951-395-3288
  • Fax:
Mailing address:
  • Phone: 951-395-3288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT115818
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: