MEDICARE: TANIKA C COOK LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	178.012123	IL
2	101YP2500X	Professional Counselor	178-012123	IL

General Provider Information

NPI Number	:	1063900926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANIKA C COOK LPC

Provider Business Mailing Address
First Line	:	3204 EAGLE WAY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60678-1032
Country	:	US
Telephone Number	:	630-717-2258
Fax Number	:

Provider Business Practice Location Address
First Line	:	3828 W TAYLOR ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-4027
Country	:	US
Telephone Number	:	773-826-1916
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2018
Last Update Date	:	09/25/2018

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