Provider Demographics
NPI:1538822697
Name:COOK, MIKE NUNAN (LPC)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:NUNAN
Last Name:COOK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1415
Mailing Address - Country:US
Mailing Address - Phone:618-624-5771
Mailing Address - Fax:
Practice Address - Street 1:200 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1415
Practice Address - Country:US
Practice Address - Phone:618-624-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1598939308OtherKARLA SMITH BEHAVIORAL HEALTH