Provider Demographics
NPI:1780007450
Name:GARY D. COBB, PH.D., P.C.
Entity Type:Organization
Organization Name:GARY D. COBB, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-883-4774
Mailing Address - Street 1:4001 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2917
Mailing Address - Country:US
Mailing Address - Phone:703-883-4774
Mailing Address - Fax:703-218-1824
Practice Address - Street 1:4001 FAIR RIDGE DR
Practice Address - Street 2:SUITE 305
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2917
Practice Address - Country:US
Practice Address - Phone:703-883-4774
Practice Address - Fax:703-218-1824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001673103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA630903Medicare PIN