Provider Demographics
NPI:1205259892
Name:COBB, DERRICK (CASAC)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:COBB
Suffix:
Gender:M
Credentials:CASAC
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 523
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-0523
Mailing Address - Country:US
Mailing Address - Phone:631-205-8044
Mailing Address - Fax:
Practice Address - Street 1:7 SEAFIELD LN
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-2714
Practice Address - Country:US
Practice Address - Phone:631-205-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-02
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26043324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility