Provider Demographics
NPI:1376815480
Name:COBB, KENNETH VANCE JR (LMSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:VANCE
Last Name:COBB
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22336 MILITARY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2717
Mailing Address - Country:US
Mailing Address - Phone:313-407-1238
Mailing Address - Fax:
Practice Address - Street 1:1600 PORTER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1936
Practice Address - Country:US
Practice Address - Phone:313-963-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-04
Last Update Date:2012-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010891471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical