Provider Demographics
NPI:1649989146
Name:COCHRAN, MICHAEL BRIAN (SUDPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRIAN
Last Name:COCHRAN
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLD PACIFIC HWY SE APT B105
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-9570
Mailing Address - Country:US
Mailing Address - Phone:360-559-9969
Mailing Address - Fax:
Practice Address - Street 1:9500 FRONT ST S STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-9415
Practice Address - Country:US
Practice Address - Phone:253-655-0645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61365459101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)