Healthcare Provider Details

I. General information

NPI: 1497803944
Provider Name (Legal Business Name): ANTONIO DESHUN COOK OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3384 FOREST HILL DR
BELDEN MS
38826-9442
US

IV. Provider business mailing address

3384 FOREST HILL DR
BELDEN MS
38826-9442
US

V. Phone/Fax

Practice location:
  • Phone: 662-871-2080
  • Fax:
Mailing address:
  • Phone: 662-871-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA3621
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT2248
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: