=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568246924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN JOSEPH COCHRANE LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2023
-----------------------------------------------------
Last Update Date | 08/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 763 BURNSIDE AVE
-----------------------------------------------------
City | EAST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06108-2791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-291-9154
-----------------------------------------------------
Fax | 860-291-9728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 CARNOUSTIE CIR
-----------------------------------------------------
City | BLOOMFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06002-2380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-777-0439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 8703
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------