Healthcare Provider Details

I. General information

NPI: 1487375234
Provider Name (Legal Business Name): RAMIYAH COCKRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NOBLE LN
CORRALES NM
87048-7704
US

IV. Provider business mailing address

PO BOX 66375
ALBUQUERQUE NM
87193-6375
US

V. Phone/Fax

Practice location:
  • Phone: 505-492-5891
  • Fax:
Mailing address:
  • Phone: 505-492-5891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-230091
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: