Healthcare Provider Details

I. General information

NPI: 1184590747
Provider Name (Legal Business Name): 1402 COCKRELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4012 COCKRELL LN
SPRINGFIELD IL
62711-8327
US

IV. Provider business mailing address

6317 N MONTICELLO AVE
CHICAGO IL
60659-1209
US

V. Phone/Fax

Practice location:
  • Phone: 847-324-3543
  • Fax:
Mailing address:
  • Phone: 847-324-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SARIAH HOPKINS
Title or Position: COMPLIANCE OFFICER
Credential: CHC
Phone: 847-324-3543