Provider Demographics
NPI:1336643592
Name:COBB, MIKIELA DANIELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIKIELA
Middle Name:DANIELLE
Last Name:COBB
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 SHERWOOD RD APT 3
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-2101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10522 S CICERO AVE STE 401
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5288
Practice Address - Country:US
Practice Address - Phone:708-406-9641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009760103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical