Provider Demographics
NPI:1588929434
Name:COCHRAN, MACKENZIE (LISW-CP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:COCHRAN
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 RADDISON LN
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456
Mailing Address - Country:US
Mailing Address - Phone:812-499-1953
Mailing Address - Fax:
Practice Address - Street 1:2100 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-1230
Practice Address - Country:US
Practice Address - Phone:843-852-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
SC12292104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid