Provider Demographics
NPI:1407362296
Name:COBB, KELLY REAGAN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:REAGAN
Last Name:COBB
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:REAGAN
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:802 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631-3541
Mailing Address - Country:US
Mailing Address - Phone:360-244-1991
Mailing Address - Fax:
Practice Address - Street 1:802 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-3541
Practice Address - Country:US
Practice Address - Phone:360-244-1991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-16
Last Update Date:2017-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60812824225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist