Provider Demographics
NPI:1114657632
Name:COLE, KHALIAH LABELLE
Entity Type:Individual
Prefix:
First Name:KHALIAH
Middle Name:LABELLE
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 1:4656 MIDWAY AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-1354
Mailing Address - Country:US
Mailing Address - Phone:937-856-3831
Mailing Address - Fax:
Practice Address - Street 1:4656 MIDWAY AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-1354
Practice Address - Country:US
Practice Address - Phone:937-856-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0486045Medicaid