MEDICARE: DATY H COOKE

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	225X00000X	Occupational Therapist	OT1506	MS

General Provider Information

NPI Number	:	1508317603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DATY H COOKE

Provider Business Mailing Address
First Line	:	2 CAROLINE CV
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-6602
Country	:	US
Telephone Number	:	662-822-4500
Fax Number	:	662-843-5401

Provider Business Practice Location Address
First Line	:	4036 HIGHWAY 8
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-8551
Country	:	US
Telephone Number	:	662-843-4014
Fax Number	:	662-843-5401

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

Provider Enumeration Date	:	10/24/2016
Last Update Date	:	10/24/2016

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