Provider Demographics
NPI:1194350868
Name:COCKRELL, KRISTEN TAYLOR
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:TAYLOR
Last Name:COCKRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PROVIDENCE HWY
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1881
Mailing Address - Country:US
Mailing Address - Phone:781-326-8332
Mailing Address - Fax:
Practice Address - Street 1:200 PROVIDENCE HWY
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1881
Practice Address - Country:US
Practice Address - Phone:781-326-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA23581OtherLICENSE NUMBER