Healthcare Provider Details

I. General information

NPI: 1770955262
Provider Name (Legal Business Name): HEATHER ALISON COOK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E POWELL BLVD
GRESHAM OR
97030-7605
US

IV. Provider business mailing address

14385 SE LUSTED RD
SANDY OR
97055-7551
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-1500
  • Fax:
Mailing address:
  • Phone: 575-312-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number20464
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: