Healthcare Provider Details

I. General information

NPI: 1043909005
Provider Name (Legal Business Name): COURTNEY LONGUET COOK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3753 HAWKS LANDING CIR
PACE FL
32571-9656
US

IV. Provider business mailing address

3753 HAWKS LANDING CIR
PACE FL
32571-9656
US

V. Phone/Fax

Practice location:
  • Phone: 850-529-9419
  • Fax:
Mailing address:
  • Phone: 850-529-9419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12578
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: