Provider Demographics
NPI:1730842600
Name:COBB, FREDDIE D (LADC)
Entity type:Individual
Prefix:
First Name:FREDDIE
Middle Name:D
Last Name:COBB
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7911 HEMMINGWOOD RD APT 4
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-3804
Mailing Address - Country:US
Mailing Address - Phone:901-859-3687
Mailing Address - Fax:
Practice Address - Street 1:5220 PARK AVE STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3541
Practice Address - Country:US
Practice Address - Phone:901-859-3687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC0000001149101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)