Healthcare Provider Details

I. General information

NPI: 1811463938
Provider Name (Legal Business Name): TERRY LEE ROOK JR. LCDC III, LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 MADISON AVE
COVINGTON KY
41011-3330
US

IV. Provider business mailing address

1041 BEECHMEADOW LN
CINCINNATI OH
45238-4304
US

V. Phone/Fax

Practice location:
  • Phone: 859-360-0250
  • Fax:
Mailing address:
  • Phone: 513-488-3563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number021024
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: