Provider Demographics
NPI:1407449424
Name:COCHRAN, ELYISA
Entity Type:Individual
Prefix:
First Name:ELYISA
Middle Name:
Last Name:COCHRAN
Suffix:
Gender:F
Credentials:
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 2567
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-2567
Mailing Address - Country:US
Mailing Address - Phone:706-842-5330
Mailing Address - Fax:706-842-5340
Practice Address - Street 1:1048 WILDWOOD CENTRE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8420
Practice Address - Country:US
Practice Address - Phone:803-830-4974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-22-230609106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician