Provider Demographics
NPI: | 1255838413 |
---|---|
Name: | COLEY, JAMES MICHAEL |
Entity Type: | Individual |
Prefix: | MR |
First Name: | JAMES |
Middle Name: | MICHAEL |
Last Name: | COLEY |
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: | 5201 S VERMONT AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | LOS ANGELES |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90037-3527 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 323-751-2677 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3850 CRENSHAW BLVD |
Practice Address - Street 2: | |
Practice Address - City: | LOS ANGELES |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90008-1821 |
Practice Address - Country: | US |
Practice Address - Phone: | 323-451-6133 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2018-04-12 |
Last Update Date: | 2024-02-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | ASW81282 | 101YM0800X |
171M0000X | 171M00000X | |
CA | ASW121172 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty |