Provider Demographics
NPI:1093314551
Name:COLE, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:COLE
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:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:IA
Mailing Address - Zip Code:50655-0092
Mailing Address - Country:US
Mailing Address - Phone:319-481-2296
Mailing Address - Fax:
Practice Address - Street 1:104 W 2ND ST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:IA
Practice Address - Zip Code:50674-1145
Practice Address - Country:US
Practice Address - Phone:319-481-2296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-25
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007278104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker