Provider Demographics
NPI:1164660775
Name:COLE, DAVID L (LCSW, LPHA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:COLE
Suffix:
Gender:M
Credentials:LCSW, LPHA
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 163
Mailing Address - Street 2:12 W. HARRISON
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-0163
Mailing Address - Country:US
Mailing Address - Phone:217-728-4358
Mailing Address - Fax:217-728-2270
Practice Address - Street 1:12 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-1907
Practice Address - Country:US
Practice Address - Phone:217-728-4358
Practice Address - Fax:217-728-2270
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0110511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical