Provider Demographics
NPI:1265660963
Name:COLE, GARY MICHAEL (LLP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:MICHAEL
Last Name:COLE
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 WALL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DELTON
Mailing Address - State:MI
Mailing Address - Zip Code:49046-9517
Mailing Address - Country:US
Mailing Address - Phone:269-623-5771
Mailing Address - Fax:269-623-5771
Practice Address - Street 1:1115 BALL AVE NE BLDG C
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-632-7744
Practice Address - Fax:616-632-7744
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008599103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling