Provider Demographics
NPI:1255144754
Name:COBB, STACIE (CMT)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:COBB
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12185 QUINN ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-1812
Mailing Address - Country:US
Mailing Address - Phone:763-229-5368
Mailing Address - Fax:
Practice Address - Street 1:1902 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2578
Practice Address - Country:US
Practice Address - Phone:763-229-5368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist