Provider Demographics
NPI:1760262547
Name:COBB, DERRICK A
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:A
Last Name:COBB
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 1:1901 BARNEY RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-4301
Mailing Address - Country:US
Mailing Address - Phone:916-642-7800
Mailing Address - Fax:
Practice Address - Street 1:1901 BARNEY RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-4301
Practice Address - Country:US
Practice Address - Phone:916-642-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician