Healthcare Provider Details

I. General information

NPI: 1487647384
Provider Name (Legal Business Name): STEVEN M COBB PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 05/02/2013
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: 575-622-3037
Mailing address:
  • Phone: 575-622-6437
  • Fax: 575-622-3037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number458
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number458
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number458
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: