Healthcare Provider Details

I. General information

NPI: 1508578121
Provider Name (Legal Business Name): COOK CHILDREN'S MEDICAL CENTER - PROSPER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W UNIVERSITY DR
PROSPER TX
75078-9805
US

IV. Provider business mailing address

PO BOX 730108
DALLAS TX
75373-0108
US

V. Phone/Fax

Practice location:
  • Phone: 940-484-4311
  • Fax:
Mailing address:
  • Phone: 682-885-1860
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CORY R RHOADES
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 682-885-4880