Healthcare Provider Details

I. General information

NPI: 1063309920
Provider Name (Legal Business Name): MITCHELL BRIAN COBB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7131 TRILLIUM TRL
PENDLETON IN
46064-9223
US

IV. Provider business mailing address

7131 TRILLIUM TRL
PENDLETON IN
46064-9223
US

V. Phone/Fax

Practice location:
  • Phone: 765-615-6002
  • Fax:
Mailing address:
  • Phone: 765-615-6002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: