Provider Demographics
NPI:1366754061
Name:KOBB, SHARLENE KAY (MATS)
Entity type:Individual
Prefix:MS
First Name:SHARLENE
Middle Name:KAY
Last Name:KOBB
Suffix:
Gender:F
Credentials:MATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6134
Mailing Address - Country:US
Mailing Address - Phone:574-274-9049
Mailing Address - Fax:888-647-0543
Practice Address - Street 1:115 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6134
Practice Address - Country:US
Practice Address - Phone:574-274-9049
Practice Address - Fax:888-647-0543
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200948010A171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200948010AOtherMEDICAID A D AND TBI WAIVER