Provider Demographics
NPI:1417541491
Name:COGDELL, MAYA
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:COGDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5577 AIRPORT HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-7364
Mailing Address - Country:US
Mailing Address - Phone:419-214-1770
Mailing Address - Fax:419-214-0922
Practice Address - Street 1:5577 AIRPORT HWY STE 102
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-7364
Practice Address - Country:US
Practice Address - Phone:419-214-1770
Practice Address - Fax:419-214-0922
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-21
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.175789101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.175789OtherCHEMICAL DEPENDENCY PROFESSIONALS BOARD