Provider Demographics
NPI:1184633810
Name:COBO, EVITA (LCMHC)
Entity type:Individual
Prefix:
First Name:EVITA
Middle Name:
Last Name:COBO
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 MT ANTHONY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH POWNAL
Mailing Address - State:VT
Mailing Address - Zip Code:05260-9720
Mailing Address - Country:US
Mailing Address - Phone:802-249-0645
Mailing Address - Fax:802-823-5356
Practice Address - Street 1:185 NORTH ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1813
Practice Address - Country:US
Practice Address - Phone:802-249-0645
Practice Address - Fax:802-823-5356
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000124101Y00000X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
360028OtherMANAGED HEALTH NET
18519OtherBLUE CROSS
VT1010685Medicaid
2186353OtherCIGNA