=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598190951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES RAY COCHRAN JR. LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2013
-----------------------------------------------------
Last Update Date | 07/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3611 SENECA AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90039-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-627-7020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3611 SENECA AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90039-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-627-7020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 81770
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------