Healthcare Provider Details

I. General information

NPI: 1093805194
Provider Name (Legal Business Name): PRISCILLA D. COOKE MSW, LCSW, LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WEST AVE
KANNAPOLIS NC
28081-4332
US

IV. Provider business mailing address

250 POST OAK RD
KERNERSVILLE NC
27284-8027
US

V. Phone/Fax

Practice location:
  • Phone: 704-630-6634
  • Fax: 866-828-5520
Mailing address:
  • Phone: 336-993-1859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1369
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC002692
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC002692
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: