Healthcare Provider Details

I. General information

NPI: 1639621469
Provider Name (Legal Business Name): MICHELE COOKIEANOS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 06/07/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 HOLMES CT STE 100
POOLER GA
31322-4801
US

IV. Provider business mailing address

6 HOLMES CT STE 100
POOLER GA
31322-4801
US

V. Phone/Fax

Practice location:
  • Phone: 912-254-4401
  • Fax: 912-330-4319
Mailing address:
  • Phone: 912-254-4401
  • Fax: 912-330-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC005617
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: