Provider Demographics
NPI:1194497594
Name:COBB, LATOYA
Entity type:Individual
Prefix:
First Name:LATOYA
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 1:1777 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30337-2701
Mailing Address - Country:US
Mailing Address - Phone:929-232-4091
Mailing Address - Fax:
Practice Address - Street 1:308 UNIONVILLE INDIAN TRAIL RD W STE C
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5551
Practice Address - Country:US
Practice Address - Phone:214-437-2272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5469852OtherCOSMETOLOGY LICENSE