Provider Demographics
NPI:1144794132
Name:SMITH, COLE LOGAN
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:LOGAN
Last Name:SMITH
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 1:6235 DE ORO CT
Mailing Address - Street 2:
Mailing Address - City:WINNEMUCCA
Mailing Address - State:NV
Mailing Address - Zip Code:89445-8316
Mailing Address - Country:US
Mailing Address - Phone:775-304-1689
Mailing Address - Fax:
Practice Address - Street 1:6235 DE ORO CT
Practice Address - Street 2:
Practice Address - City:WINNEMUCCA
Practice Address - State:NV
Practice Address - Zip Code:89445-8316
Practice Address - Country:US
Practice Address - Phone:775-304-1689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician