MEDICARE: LISA S COOK MA

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1497993760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA S COOK MA

Provider Business Mailing Address
First Line	:	5023 PECO RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-3468
Country	:	US
Telephone Number	:	704-995-2900
Fax Number	:	704-846-2958

Provider Business Practice Location Address
First Line	:	5023 PECO RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-3468
Country	:	US
Telephone Number	:	704-995-2900
Fax Number	:	704-846-2958

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

Provider Enumeration Date	:	01/26/2009
Last Update Date	:	01/26/2009

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