Provider Demographics
NPI:1730436239
Name:COSBY, BRENNA (LICENSED SOCIAL WORK)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:COSBY
Suffix:
Gender:F
Credentials:LICENSED SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 AUBURN ROAD HWY 14
Mailing Address - Street 2:
Mailing Address - City:NOTASULGA
Mailing Address - State:AL
Mailing Address - Zip Code:36866
Mailing Address - Country:US
Mailing Address - Phone:614-403-7089
Mailing Address - Fax:
Practice Address - Street 1:686 AUBURN ROAD HWY 14
Practice Address - Street 2:
Practice Address - City:NOTASULGA
Practice Address - State:AL
Practice Address - Zip Code:36866
Practice Address - Country:US
Practice Address - Phone:614-403-7089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS090055-4104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1548387582Medicare NSC