Provider Demographics
NPI:1760713119
Name:COSBY, EMMA STACY (LCSW, PIP)
Entity Type:Individual
Prefix:MRS
First Name:EMMA
Middle Name:STACY
Last Name:COSBY
Suffix:
Gender:F
Credentials:LCSW, PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 W BYPASS
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420
Mailing Address - Country:US
Mailing Address - Phone:334-222-3555
Mailing Address - Fax:334-427-9522
Practice Address - Street 1:614 W BYPASS
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-4731
Practice Address - Country:US
Practice Address - Phone:334-222-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3184C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1679807291OtherCMS