Provider Demographics
NPI:1982050191
Name:COCHRAN, KELLE (LISW)
Entity type:Individual
Prefix:
First Name:KELLE
Middle Name:
Last Name:COCHRAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35302
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-5302
Mailing Address - Country:US
Mailing Address - Phone:505-440-3611
Mailing Address - Fax:
Practice Address - Street 1:790 TRAMWAY LN NE APT 9A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-1625
Practice Address - Country:US
Practice Address - Phone:505-440-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-068091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical