Provider Demographics
NPI:1487647384
Name:COBB, STEVEN M (PHD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:M
Last Name:COBB
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 3182
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-3182
Mailing Address - Country:US
Mailing Address - Phone:575-622-6437
Mailing Address - Fax:575-622-3037
Practice Address - Street 1:400 N PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 990-B
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4754
Practice Address - Country:US
Practice Address - Phone:575-622-6437
Practice Address - Fax:575-622-3037
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM458103TC0700X, 103T00000X, 103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN0526Medicaid
NMR91407Medicare UPIN