Healthcare Provider Details

I. General information

NPI: 1700890258
Provider Name (Legal Business Name): CAROLYN LACY COOK MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 W BROADWAY STE 201
MONONA WI
53713-1828
US

IV. Provider business mailing address

1532 W BROADWAY STE 201
MONONA WI
53713-1828
US

V. Phone/Fax

Practice location:
  • Phone: 608-223-1506
  • Fax:
Mailing address:
  • Phone: 608-223-1506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number5639-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: