Provider Demographics
NPI:1679926166
Name:COCKRILL, KEVONTE (PTA, CLT, MS)
Entity type:Individual
Prefix:MR
First Name:KEVONTE
Middle Name:
Last Name:COCKRILL
Suffix:
Gender:M
Credentials:PTA, CLT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12639 COIT RD APT 3314
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-1726
Mailing Address - Country:US
Mailing Address - Phone:310-498-9004
Mailing Address - Fax:
Practice Address - Street 1:206 STORRS STREET
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TEXAS
Practice Address - Zip Code:75219
Practice Address - Country:US
Practice Address - Phone:972-771-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA44922251P0200X, 225200000X
PATEI005154225200000X
226300000X
TX2133780225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist