Provider Demographics
NPI:1053775353
Name:COOK, SUSIE
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2076
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-2076
Mailing Address - Country:US
Mailing Address - Phone:707-484-5427
Mailing Address - Fax:
Practice Address - Street 1:255 W NAPA ST
Practice Address - Street 2:#D
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6559
Practice Address - Country:US
Practice Address - Phone:707-484-5427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist