Basic Information
| Provider Information | |||||||||
| NPI: | 1376815480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COBB | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | VANCE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22336 MILITARY ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481242717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134071238 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 PORTER ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482161936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139636601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2012 | ||||||||
| LastUpdateDate: | 02/04/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801089147 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.