Provider Demographics
NPI:1114624053
Name:COBB, MANDY
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:COBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 BONHOMME AVE STE 1800
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1931
Mailing Address - Country:US
Mailing Address - Phone:636-202-0693
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:11432 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6925
Practice Address - Country:US
Practice Address - Phone:217-525-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024022024103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst