Provider Demographics
NPI:1538900444
Name:COBB, MARTY (LCADC)
Entity type:Individual
Prefix:MR
First Name:MARTY
Middle Name:
Last Name:COBB
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 374
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-0029
Mailing Address - Country:US
Mailing Address - Phone:270-247-4212
Mailing Address - Fax:270-247-2017
Practice Address - Street 1:PO BOX 374
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-0029
Practice Address - Country:US
Practice Address - Phone:270-247-4212
Practice Address - Fax:270-247-2017
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY293683101YM0800X
KY290407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health