Healthcare Provider Details

I. General information

NPI: 1457664542
Provider Name (Legal Business Name): MICHELLE YVONNE COBLER O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2010
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 S 105TH ST
EDWARDSVILLE KS
66111-3490
US

IV. Provider business mailing address

1807 S 105TH ST
EDWARDSVILLE KS
66111-3490
US

V. Phone/Fax

Practice location:
  • Phone: 913-422-8233
  • Fax:
Mailing address:
  • Phone: 913-422-8233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2008032208
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: