Provider Demographics
NPI:1780224394
Name:COCKERHAM, KEWANNA KEION
Entity Type:Individual
Prefix:
First Name:KEWANNA
Middle Name:KEION
Last Name:COCKERHAM
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 1:5 MARCUS CHRISTIAN CIR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70126-5657
Mailing Address - Country:US
Mailing Address - Phone:504-405-0972
Mailing Address - Fax:
Practice Address - Street 1:733 DANTE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-1013
Practice Address - Country:US
Practice Address - Phone:504-517-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-11
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
LA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7770000644136203Medicaid