Healthcare Provider Details

I. General information

NPI: 1538900444
Provider Name (Legal Business Name): MARTY COBB LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N 9TH ST
MAYFIELD KY
42066-1800
US

IV. Provider business mailing address

PO BOX 374
MAYFIELD KY
42066-0029
US

V. Phone/Fax

Practice location:
  • Phone: 270-247-4212
  • Fax: 270-247-2017
Mailing address:
  • Phone: 270-247-4212
  • Fax: 270-247-2017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number290407
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number293683
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: