Healthcare Provider Details

I. General information

NPI: 1396065033
Provider Name (Legal Business Name): TIFFANY A COOK LCNHCS, LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 COX RD
GASTONIA NC
28054-0628
US

IV. Provider business mailing address

13726 DEALTRY LN
FORT MILL SC
29707-9001
US

V. Phone/Fax

Practice location:
  • Phone: 704-865-1558
  • Fax: 704-865-9908
Mailing address:
  • Phone: 704-293-4297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1639
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: