Provider Demographics
NPI:1962737759
Name:COCKRUM, ALICIA DAWN (PSYD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:DAWN
Last Name:COCKRUM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:DAWN
Other - Last Name:BUNTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 W NAPA ST STE K
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-6546
Mailing Address - Country:US
Mailing Address - Phone:707-816-2400
Mailing Address - Fax:
Practice Address - Street 1:255 W NAPA ST STE K
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6546
Practice Address - Country:US
Practice Address - Phone:707-816-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23519103TC0700X
103TH0004X, 103TF0000X, 103TM1800X, 103TR0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA268623Medicaid
CAFHC70042OtherSANTA CRUZ COUNTY MEDI-CAL ID#
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE PTAN#