Provider Demographics
NPI:1952956799
Name:COCHRAN, TYRA ROSE (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:ROSE
Last Name:COCHRAN
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 MCCLUNG RD
Mailing Address - Street 2:
Mailing Address - City:RENICK
Mailing Address - State:WV
Mailing Address - Zip Code:24966-7326
Mailing Address - Country:US
Mailing Address - Phone:304-956-0508
Mailing Address - Fax:
Practice Address - Street 1:7576 SENECA TRAIL
Practice Address - Street 2:RT 219 N
Practice Address - City:HILLSBORO
Practice Address - State:WV
Practice Address - Zip Code:24946
Practice Address - Country:US
Practice Address - Phone:304-742-2025
Practice Address - Fax:304-653-4200
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSW071915174101Y00000X, 101YM0800X, 101YP2500X, 1041C0700X, 2080P0006X, 251S00000X, 261QM0801X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)