Healthcare Provider Details

I. General information

NPI: 1245754753
Provider Name (Legal Business Name): DIEDRE COOK MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MICHIGAN AVE
LOGANSPORT IN
46947-1526
US

IV. Provider business mailing address

800 FULTON ST
LOGANSPORT IN
46947-1577
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-5151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: