Basic Information
| Provider Information | |||||||||
| NPI: | 1245657329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COCKRUM | ||||||||
| FirstName: | STEPHANY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 SCHOONER BLVD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231855277 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 576 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | FORT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236041373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147500 | ||||||||
| FaxNumber: | 7573147854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 12114 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.