MEDICARE: CARRIE C COOK CEAP, SAP, LMHC

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	101YM0800X	Mental Health Counselor	MH 3915	FL

General Provider Information

NPI Number	:	1215075452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE C COOK CEAP, SAP, LMHC

Provider Business Mailing Address
First Line	:	904 HILL DR
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-9214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4404 S FLORIDA AVE
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2169
Country	:	US
Telephone Number	:	863-709-8110
Fax Number	:	863-709-8118

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

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	07/08/2007

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