Provider Demographics
NPI:1396290359
Name:COBB, WILLARD J JR (MACC, LMFTA, LPCA)
Entity type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:J
Last Name:COBB
Suffix:JR
Gender:M
Credentials:MACC, LMFTA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E 5TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2379
Mailing Address - Country:US
Mailing Address - Phone:704-375-5354
Mailing Address - Fax:
Practice Address - Street 1:1801 E 5TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2379
Practice Address - Country:US
Practice Address - Phone:704-375-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12369101Y00000X, 101YM0800X
NC11057A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist