Healthcare Provider Details

I. General information

NPI: 1407951767
Provider Name (Legal Business Name): KATHLEEN COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2639 NEW PINERY RD STE 1
PORTAGE WI
53901-1110
US

IV. Provider business mailing address

2639 NEW PINERY RD STE 1
PORTAGE WI
53901-1110
US

V. Phone/Fax

Practice location:
  • Phone: 608-742-5020
  • Fax: 608-742-3641
Mailing address:
  • Phone: 608-742-5020
  • Fax: 608-742-3641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number656-124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: