Healthcare Provider Details

I. General information

NPI: 1902197098
Provider Name (Legal Business Name): S M COBB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PENNSYLVANIA AVE STE 990
ROSWELL NM
88201-4754
US

IV. Provider business mailing address

400 N PENNSYLVANIA AVE STE 990
ROSWELL NM
88201-4754
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 Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0005
License Number StateNM

VIII. Authorized Official

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