Healthcare Provider Details

I. General information

NPI: 1831219765
Provider Name (Legal Business Name): JOSH COOK LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6425 NICOLLET AVE THE STOREFRONT GROUP
RICHFIELD MN
55423-1668
US

IV. Provider business mailing address

3933 20TH AVE S
MINNEAPOLIS MN
55407-2929
US

V. Phone/Fax

Practice location:
  • Phone: 612-861-1675
  • Fax: 612-861-3446
Mailing address:
  • Phone: 612-483-7990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17098
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: