Provider Demographics
NPI:1669822383
Name:COSBY, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:COSBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3361 BIRCHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3682
Mailing Address - Country:US
Mailing Address - Phone:734-785-2168
Mailing Address - Fax:
Practice Address - Street 1:3361 BIRCHWOOD ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-3682
Practice Address - Country:US
Practice Address - Phone:734-785-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator