Provider Demographics
NPI:1952668337
Name:COBB, BRIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:COBB
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10474
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78766-1474
Mailing Address - Country:US
Mailing Address - Phone:360-790-1774
Mailing Address - Fax:
Practice Address - Street 1:1000 BLUE BIRD DR STE 5
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76548-1252
Practice Address - Country:US
Practice Address - Phone:360-790-1774
Practice Address - Fax:866-801-2626
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX541941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX293343403Medicaid
TX564429OtherMEDICARE