Provider Demographics
NPI:1891990214
Name:COBELL-MOORE, MARSHA (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:
Last Name:COBELL-MOORE
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:MARSHA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:1201 HERITAGE CIR
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-3744
Mailing Address - Country:US
Mailing Address - Phone:918-762-2517
Mailing Address - Fax:918-762-6646
Practice Address - Street 1:1201 HERITAGE CIR
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-3744
Practice Address - Country:US
Practice Address - Phone:918-762-2517
Practice Address - Fax:918-762-6646
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-16
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK506807YPF5Medicaid