Healthcare Provider Details

I. General information

NPI: 1669915468
Provider Name (Legal Business Name): MCCOOK THERAPY & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 S NEBRASKA ST
SALEM SD
57058-8917
US

IV. Provider business mailing address

511 S NEBRASKA ST
SALEM SD
57058-8917
US

V. Phone/Fax

Practice location:
  • Phone: 605-425-3303
  • Fax: 605-425-3306
Mailing address:
  • Phone: 605-425-3303
  • Fax: 605-425-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number1702
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number0119
License Number StateSD

VIII. Authorized Official

Name: AMY HEUMILLER
Title or Position: OWNER
Credential: OT
Phone: 605-425-3303