Healthcare Provider Details

I. General information

NPI: 1619640620
Provider Name (Legal Business Name): KRISTEN COOKE, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 RED BIRD TRL
OLD SAYBROOK CT
06475-1826
US

IV. Provider business mailing address

29 RED BIRD TRL
OLD SAYBROOK CT
06475-1826
US

V. Phone/Fax

Practice location:
  • Phone: 860-785-3403
  • Fax:
Mailing address:
  • Phone: 860-785-3403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KRISTEN COOKE
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 860-785-3403