Provider Demographics
NPI:1578208690
Name:MGBOLU, ERYN COCHRAN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ERYN
Middle Name:COCHRAN
Last Name:MGBOLU
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14051 BEACH BLVD APT 2109
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-1798
Mailing Address - Country:US
Mailing Address - Phone:706-897-9605
Mailing Address - Fax:
Practice Address - Street 1:104 ASHOURIAN AVE STE 105
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5106
Practice Address - Country:US
Practice Address - Phone:904-230-7761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist