Provider Demographics
NPI:1962228403
Name:COCKRELL, DAVID PENNA (LMT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:PENNA
Last Name:COCKRELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10605 CONCORD ST STE 410
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-2519
Mailing Address - Country:US
Mailing Address - Phone:301-221-0134
Mailing Address - Fax:
Practice Address - Street 1:10605 CONCORD ST STE 410
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2519
Practice Address - Country:US
Practice Address - Phone:301-221-0134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-30
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM00486225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist