MEDICARE: MR. EUGENE ROBERT COOK LCSW

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	1041C0700X	Clinical Social Worker	185	CO

General Provider Information

NPI Number	:	1073883054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EUGENE ROBERT COOK LCSW

Provider Business Mailing Address
First Line	:	555 EVELYN DR
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-9455
Country	:	US
Telephone Number	:	719-431-1722
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 EVELYN DR
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-9455
Country	:	US
Telephone Number	:	719-431-1722
Fax Number	:

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

Provider Enumeration Date	:	01/06/2012
Last Update Date	:	02/16/2016

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