Healthcare Provider Details

I. General information

NPI: 1861272544
Provider Name (Legal Business Name): THE T.A. COOK AGENCY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 MORRIS RD SE STE 302
WASHINGTON DC
20020
US

IV. Provider business mailing address

712 H ST NE UNIT 669
WASHINGTON DC
20002-3627
US

V. Phone/Fax

Practice location:
  • Phone: 202-873-0398
  • Fax:
Mailing address:
  • Phone: 202-873-0398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: TREVON COOK
Title or Position: CEO
Credential:
Phone: 202-873-0398