Healthcare Provider Details

I. General information

NPI: 1174235246
Provider Name (Legal Business Name): TABITHA COCHRAN CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE BLDG 15
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

12120 MENAUL BLVD NE APT 3
ALBUQUERQUE NM
87112-2428
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 228-990-5857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: