Healthcare Provider Details

I. General information

NPI: 1245453950
Provider Name (Legal Business Name): GLENN COCKRELL LCSW, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING ST
MISSOULA MT
59801-1725
US

IV. Provider business mailing address

T-9 FORT MISSOULA
MISSOULA MT
59804-7202
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-9800
  • Fax: 406-541-3032
Mailing address:
  • Phone: 406-532-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1190
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number913
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: