Provider Demographics
NPI:1487712907
Name:COOK, PHYLLIS T (CAC-AD, CCDC, ICADC)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:T
Last Name:COOK
Suffix:
Gender:F
Credentials:CAC-AD, CCDC, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8715 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:MD
Mailing Address - Zip Code:21875-2551
Mailing Address - Country:US
Mailing Address - Phone:410-221-6343
Mailing Address - Fax:410-221-6342
Practice Address - Street 1:2823 OCEAN GTWY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-3403
Practice Address - Country:US
Practice Address - Phone:410-221-6343
Practice Address - Fax:410-221-6342
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0191101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDAC0191OtherCERTIFIED ADDICTION COUNS