MEDICARE: KRISTINA COOKE, LCSW, LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1265913792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRISTINA COOKE, LCSW, LLC

Provider Business Mailing Address
First Line	:	5368 W BANK DR
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30068-1703
Country	:	US
Telephone Number	:	678-462-3579
Fax Number	:

Provider Business Practice Location Address
First Line	:	2854 JOHNSON FERRY RD STE 200
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-5699
Country	:	US
Telephone Number	:	678-462-3579
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	KRISTINA COOKE
Credential	:	LCSW, RPT-S
Telephone Number	:	678-462-3579

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	08/23/2018

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