Healthcare Provider Details

I. General information

NPI: 1023489564
Provider Name (Legal Business Name): CHARLOTTE COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E SUNSHINE ST SUITE 215
SPRINGFIELD MO
65804-1924
US

IV. Provider business mailing address

3356 E SOUTHERN HILLS BLVD #4
SPRINGFIELD MO
65804-2842
US

V. Phone/Fax

Practice location:
  • Phone: 417-551-2435
  • Fax: 417-719-7973
Mailing address:
  • Phone: 417-818-1434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2015000258
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: