Healthcare Provider Details

I. General information

NPI: 1215850664
Provider Name (Legal Business Name): COOPER LEE COBB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 BUDDY HOLLY PL
CLEAR LAKE IA
50428-3735
US

IV. Provider business mailing address

302 BRIDGE ST
PLYMOUTH IA
50464-7739
US

V. Phone/Fax

Practice location:
  • Phone: 641-352-7671
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1457649
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: