Provider Demographics
NPI:1144620568
Name:COLE, GENESIS FM
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:FM
Last Name:COLE
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 1:601 NAPA VALLEY DR APT 1032
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2358
Mailing Address - Country:US
Mailing Address - Phone:501-240-6711
Mailing Address - Fax:
Practice Address - Street 1:4107 RICHARDS RD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2653
Practice Address - Country:US
Practice Address - Phone:501-955-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor