Healthcare Provider Details

I. General information

NPI: 1225517618
Provider Name (Legal Business Name): KRISTIE NICOLE COOK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

17776 CRESCENT LAKE PL
MACOMB MI
48042-2376
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-4014
  • Fax:
Mailing address:
  • Phone: 586-850-7982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201010241
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: