Provider Demographics
NPI:1407038482
Name:COLE, LAVEENA EBONY MARIE
Entity Type:Individual
Prefix:
First Name:LAVEENA
Middle Name:EBONY MARIE
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S LINCOLN AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-5337
Mailing Address - Country:US
Mailing Address - Phone:760-782-7116
Mailing Address - Fax:
Practice Address - Street 1:630 SOUTH LINCOLN AVE
Practice Address - Street 2:#12
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020
Practice Address - Country:US
Practice Address - Phone:760-782-7116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)