Healthcare Provider Details

I. General information

NPI: 1215449079
Provider Name (Legal Business Name): KAYLEE JEAN COOK MSOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 HARRISON AVE STE A
CENTRALIA WA
98531-1300
US

IV. Provider business mailing address

27238 WEBSTER RD E
GRAHAM WA
98338-9350
US

V. Phone/Fax

Practice location:
  • Phone: 608-702-4733
  • Fax: 360-312-4204
Mailing address:
  • Phone: 253-691-3218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT61257276
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: