Provider Demographics
NPI:1104834779
Name:COCKRELL, LAURA TIPTON (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:TIPTON
Last Name:COCKRELL
Suffix:
Gender:F
Credentials:PT
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 455
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:KY
Mailing Address - Zip Code:40380
Mailing Address - Country:US
Mailing Address - Phone:606-663-8244
Mailing Address - Fax:606-663-8284
Practice Address - Street 1:436 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380
Practice Address - Country:US
Practice Address - Phone:606-663-8244
Practice Address - Fax:606-663-8284
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8700160800Medicaid
KY0917203Medicare ID - Type Unspecified