Provider Demographics
NPI:1235706268
Name:COLE, LYDIA RENEE (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:RENEE
Last Name:COLE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 PINEHURST LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2605
Mailing Address - Country:US
Mailing Address - Phone:810-624-6761
Mailing Address - Fax:
Practice Address - Street 1:3106 PINEHURST LN
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2605
Practice Address - Country:US
Practice Address - Phone:810-624-6761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011101101041C0700X
MI68511101101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical