Provider Demographics
NPI:1164179321
Name:COCKERN, SALOME (PHDWQ2)
Entity Type:Individual
Prefix:
First Name:SALOME
Middle Name:
Last Name:COCKERN
Suffix:
Gender:F
Credentials:PHDWQ2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MACK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2136
Mailing Address - Country:US
Mailing Address - Phone:313-448-9600
Mailing Address - Fax:313-448-9978
Practice Address - Street 1:400 MACK AVE STE 1
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2136
Practice Address - Country:US
Practice Address - Phone:313-448-9600
Practice Address - Fax:313-448-9978
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist