Provider Demographics
NPI:1144667056
Name:COOK, GARY NEIL (MA)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:NEIL
Last Name:COOK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3447 HOLLOW BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1717
Mailing Address - Country:US
Mailing Address - Phone:714-425-9077
Mailing Address - Fax:
Practice Address - Street 1:901 N PACIFIC COAST HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2162
Practice Address - Country:US
Practice Address - Phone:310-316-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 69151106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist