Provider Demographics
NPI:1235696089
Name:COBB, MALYNDA
Entity Type:Individual
Prefix:
First Name:MALYNDA
Middle Name:
Last Name:COBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALYNDA
Other - Middle Name:
Other - Last Name:COBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:605 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-1228
Mailing Address - Country:US
Mailing Address - Phone:580-371-8210
Mailing Address - Fax:
Practice Address - Street 1:504 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3214
Practice Address - Country:US
Practice Address - Phone:580-371-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0Medicaid