Provider Demographics
NPI:1740658996
Name:COCKRELL, VIVIAN DELORES (SPEECH PATHOLOGIST)
Entity type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:DELORES
Last Name:COCKRELL
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:MISS
Other - First Name:VIVIAN
Other - Middle Name:DELORES
Other - Last Name:BARRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SPEECH PATHOLOGIST
Mailing Address - Street 1:11960 WESTLINE INDUSTRIAL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3209
Mailing Address - Country:US
Mailing Address - Phone:314-819-0480
Mailing Address - Fax:314-275-7444
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:314-819-0480
Practice Address - Fax:314-275-7444
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO235Z00000X
IL146.000944235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist