MEDICARE: LESLIE DAVID COCKRELL LPC-A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MC61636479	WA
2	101YP2500X	Professional Counselor	89160	TX

General Provider Information

NPI Number	:	1558187674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE DAVID COCKRELL LPC-A

Provider Business Mailing Address
First Line	:	3729 LAKE KEMP
Second Line	:
City	:	ROBSTOWN
State	:	TX
Zip	:	78380-6143
Country	:	US
Telephone Number	:	361-215-9492
Fax Number	:

Provider Business Practice Location Address
First Line	:	3729 LAKE KEMP
Second Line	:
City	:	ROBSTOWN
State	:	TX
Zip	:	78380-6143
Country	:	US
Telephone Number	:	361-215-9492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2024
Last Update Date	:	01/21/2025

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