Provider Demographics
NPI:1346757903
Name:COLE, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
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 1:248 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-5219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9114 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5247
Practice Address - Country:US
Practice Address - Phone:718-722-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health