Provider Demographics
NPI:1295103141
Name:COBB, MACKENZIE D (DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:D
Last Name:COBB
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:D
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:901 ENTERPRISE PKWY
Mailing Address - Street 2:STE 900
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6250
Mailing Address - Country:US
Mailing Address - Phone:757-827-2480
Mailing Address - Fax:
Practice Address - Street 1:901 ENTERPRISE PKWY STE 900
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6250
Practice Address - Country:US
Practice Address - Phone:757-827-2480
Practice Address - Fax:757-827-2566
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017540440001Medicaid
VA30017540440003Medicaid
VA30017540440002Medicaid