=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073364329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY JO COCHRUM LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2024
-----------------------------------------------------
Last Update Date | 03/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3101 W PARK ROW DR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-3135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-888-0733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2316 GARDEN LN
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-301-3078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 65647
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------