Provider Demographics
NPI:1760270326
Name:COOK, MARY LOUISE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:COOK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742
Mailing Address - Street 2:
Mailing Address - City:CLARK FORK
Mailing Address - State:ID
Mailing Address - Zip Code:83811-0742
Mailing Address - Country:US
Mailing Address - Phone:720-495-0550
Mailing Address - Fax:
Practice Address - Street 1:3067 MOSQUITO CREEK RD
Practice Address - Street 2:
Practice Address - City:CLARK FORK
Practice Address - State:ID
Practice Address - Zip Code:83811-9825
Practice Address - Country:US
Practice Address - Phone:720-495-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator