Provider Demographics
NPI:1164966420
Name:COLE, TRACEY REGINA
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:REGINA
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 1:6605 COLONY PARK DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-3348
Mailing Address - Country:US
Mailing Address - Phone:314-749-0174
Mailing Address - Fax:
Practice Address - Street 1:3296 CAHABA HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-1653
Practice Address - Country:US
Practice Address - Phone:205-271-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1661Medicaid