Healthcare Provider Details

I. General information

NPI: 1437939659
Provider Name (Legal Business Name): KELTON COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20700 CIVIC CENTER DR
SOUTHFIELD MI
48076-4140
US

IV. Provider business mailing address

15305 GLENHURST
SOUTHGATE MI
48195-8531
US

V. Phone/Fax

Practice location:
  • Phone: 800-385-1035
  • Fax:
Mailing address:
  • Phone: 313-701-1061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: