Healthcare Provider Details

I. General information

NPI: 1275787699
Provider Name (Legal Business Name): STEVEN MICHAEL COBB PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PENNSYLVANIA AVE SUITE 990-B
ROSWELL NM
88201-4754
US

IV. Provider business mailing address

PO BOX 3182
ROSWELL NM
88202-3182
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-6437
  • Fax:
Mailing address:
  • Phone: 575-622-6437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0458
License Number StateNM

VIII. Authorized Official

Name: STEVEN M COBB
Title or Position: OWNER
Credential: PHD
Phone: 575-622-6437