Provider Demographics
NPI:1376101618
Name:COLE, BRENDAN (MA)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 FAIRVIEW AVE NE # 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1521
Mailing Address - Country:US
Mailing Address - Phone:952-288-9474
Mailing Address - Fax:
Practice Address - Street 1:781 KENMOOR AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8628
Practice Address - Country:US
Practice Address - Phone:616-200-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNBWW124050534001OtherBLUE CROSS BLUE SHIELD