Provider Demographics
NPI:1528364114
Name:COCHRAN, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
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 1987
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-1987
Mailing Address - Country:US
Mailing Address - Phone:530-626-3105
Mailing Address - Fax:530-642-1233
Practice Address - Street 1:4300 FORNI RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-7013
Practice Address - Country:US
Practice Address - Phone:530-626-3105
Practice Address - Fax:530-642-1233
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health