Provider Demographics
NPI:1104027812
Name:COBB, KIM (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:COBB
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SYCAMORE CT
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5017
Mailing Address - Country:US
Mailing Address - Phone:773-374-9451
Mailing Address - Fax:
Practice Address - Street 1:36 SYCAMORE CT
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5017
Practice Address - Country:US
Practice Address - Phone:773-374-9451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0081645144OtherBLUE CROSS BLUE SHIELD