Healthcare Provider Details

I. General information

NPI: 1740702042
Provider Name (Legal Business Name): LAKEITA CHARMAIN COBB LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35425 W MICHIGAN AVE
WAYNE MI
48184-9800
US

IV. Provider business mailing address

19074 LISTER AVE
EASTPOINTE MI
48021-2740
US

V. Phone/Fax

Practice location:
  • Phone: 734-467-7600
  • Fax: 734-467-7636
Mailing address:
  • Phone: 313-805-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801108637
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801099120
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801108637
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: