Provider Demographics
NPI:1801133459
Name:COBB COMMUNITY SERVICES BOARD
Entity type:Organization
Organization Name:COBB COMMUNITY SERVICES BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TOD
Authorized Official - Middle Name:
Authorized Official - Last Name:CITRON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:770-429-5000
Mailing Address - Street 1:3830 S COBB DR SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-5532
Mailing Address - Country:US
Mailing Address - Phone:770-429-5020
Mailing Address - Fax:678-213-1450
Practice Address - Street 1:218 SOUTH AVE SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2384
Practice Address - Country:US
Practice Address - Phone:770-429-5020
Practice Address - Fax:678-213-1450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000599783QMedicaid