Healthcare Provider Details

I. General information

NPI: 1326289513
Provider Name (Legal Business Name): SHANNON COOK. PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 FAULKNER LN #108
TRINITY FL
34655-3667
US

IV. Provider business mailing address

7220 FAULKNER LN #108
TRINITY FL
34655-3667
US

V. Phone/Fax

Practice location:
  • Phone: 727-255-3736
  • Fax:
Mailing address:
  • Phone: 727-255-3736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 7486
License Number StateFL

VIII. Authorized Official

Name: DR. SHANNON COOK
Title or Position: SOLE MENBER
Credential: PH.D.
Phone: 727-255-3736