Provider Demographics
NPI:1164990438
Name:COLE, BENJAMIN LEWIS
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:LEWIS
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 1:3754 W INDIAN TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-4700
Mailing Address - Country:US
Mailing Address - Phone:509-280-2338
Mailing Address - Fax:
Practice Address - Street 1:3754 W INDIAN TRAIL RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-4700
Practice Address - Country:US
Practice Address - Phone:509-280-2338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WACG60847191106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator