Healthcare Provider Details

I. General information

NPI: 1942604764
Provider Name (Legal Business Name): SUE COOK L.AC., LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4711 N BROADWAY ST
CHICAGO IL
60640-4908
US

IV. Provider business mailing address

4711 N BROADWAY ST
CHICAGO IL
60640-4908
US

V. Phone/Fax

Practice location:
  • Phone: 312-279-9981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150105107
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.001119
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: