Healthcare Provider Details

I. General information

NPI: 1093629016
Provider Name (Legal Business Name): NICOLE VERNICE COSBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17320 W 12 MILE RD STE 101
SOUTHFIELD MI
48076-2102
US

IV. Provider business mailing address

17320 W 12 MILE RD STE 101
SOUTHFIELD MI
48076-2102
US

V. Phone/Fax

Practice location:
  • Phone: 248-727-3456
  • Fax:
Mailing address:
  • Phone: 248-727-3456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: