Provider Demographics
NPI:1245607233
Name:COLE, JOSHUA ALLEN
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ALLEN
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 1:1221 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2092
Mailing Address - Country:US
Mailing Address - Phone:810-488-0787
Mailing Address - Fax:810-294-5356
Practice Address - Street 1:1221 BRIARWOOD DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2092
Practice Address - Country:US
Practice Address - Phone:810-488-0789
Practice Address - Fax:810-294-5356
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501006219225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist