Provider Demographics
NPI:1982310249
Name:COGBILL, JUSTIN FLYNN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:FLYNN
Last Name:COGBILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2844 COLOMA ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4406
Mailing Address - Country:US
Mailing Address - Phone:530-626-9240
Mailing Address - Fax:
Practice Address - Street 1:5607 MOUNT MURPHY RD.
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633
Practice Address - Country:US
Practice Address - Phone:530-333-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R1493861222101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)