Basic Information
| Provider Information | |||||||||
| NPI: | 1841782059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COBB | ||||||||
| FirstName: | TALIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7232 JUSTIN WAY | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440604881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405788200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7232 JUSTIN WAY | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440604881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405788200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2018 | ||||||||
| LastUpdateDate: | 08/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | S.2004821 | OH | N | Behavioral Health & Social Service Providers | Social Worker | School | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | S.2004821 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0403419 | 05 | OH | MEDICAID |