Provider Demographics
NPI:1821623737
Name:COBALT THERAPY, LLC
Entity type:Organization
Organization Name:COBALT THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN-MARIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:352-508-7789
Mailing Address - Street 1:1303 LIMIT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-3135
Mailing Address - Country:US
Mailing Address - Phone:352-818-7368
Mailing Address - Fax:352-855-0459
Practice Address - Street 1:1303 LIMIT AVE STE 201
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-3135
Practice Address - Country:US
Practice Address - Phone:352-508-7789
Practice Address - Fax:352-855-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-11
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty