Provider Demographics
NPI:1730245085
Name:COOK, SHARON IRENE IV (PT)
Entity type:Individual
Prefix:MS
First Name:SHARON
Middle Name:IRENE
Last Name:COOK
Suffix:IV
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 N HAMPTON DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1169
Mailing Address - Country:US
Mailing Address - Phone:770-422-0101
Mailing Address - Fax:770-422-2097
Practice Address - Street 1:3618 N HAMPTON DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1169
Practice Address - Country:US
Practice Address - Phone:770-422-0101
Practice Address - Fax:770-422-2097
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000624742CMedicaid
GA307628OtherWELLCARE