Provider Demographics
NPI:1174604771
Name:COBLENTZ, ELVIN B (PHD)
Entity type:Individual
Prefix:DR
First Name:ELVIN
Middle Name:B
Last Name:COBLENTZ
Suffix:
Gender:M
Credentials:PHD
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 158
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44610-0158
Mailing Address - Country:US
Mailing Address - Phone:330-893-2100
Mailing Address - Fax:330-893-3732
Practice Address - Street 1:5130 TR 359
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:OH
Practice Address - Zip Code:44610
Practice Address - Country:US
Practice Address - Phone:330-893-2100
Practice Address - Fax:330-893-2100
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4532103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0903786Medicaid
OHCOCP 11491Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER