Provider Demographics
NPI:1679625297
Name:COOK, BRYAN J (TLMLP)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:COOK
Suffix:
Gender:M
Credentials:TLMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701
Mailing Address - Country:US
Mailing Address - Phone:620-223-5030
Mailing Address - Fax:620-223-1650
Practice Address - Street 1:212 STATE STREET
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701
Practice Address - Country:US
Practice Address - Phone:620-223-5030
Practice Address - Fax:620-223-1650
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS960103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical