Provider Demographics
NPI:1245657329
Name:COCKRUM, STEPHANY ANNE
Entity type:Individual
Prefix:MS
First Name:STEPHANY
Middle Name:ANNE
Last Name:COCKRUM
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 1:505 SCHOONER BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1373
Practice Address - Country:US
Practice Address - Phone:757-314-7500
Practice Address - Fax:757-314-7854
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD121141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical