Provider Demographics
NPI:1053328583
Name:COCKERILL, KENNETH DALE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DALE
Last Name:COCKERILL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 ORKNEY PL
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-2126
Mailing Address - Country:US
Mailing Address - Phone:530-276-9200
Mailing Address - Fax:
Practice Address - Street 1:855 CANYON RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-5544
Practice Address - Country:US
Practice Address - Phone:530-378-1855
Practice Address - Fax:530-378-0857
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 21608104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker