Healthcare Provider Details

I. General information

NPI: 1932245867
Provider Name (Legal Business Name): PHILIP G COOKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 TIMBER LN
OXFORD MS
38655-5852
US

IV. Provider business mailing address

407 TIMBER LN
OXFORD MS
38655-5852
US

V. Phone/Fax

Practice location:
  • Phone: 662-236-2142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberMS 223
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: