Provider Demographics
NPI:1447402631
Name:COLE, LISA R (LMSW, ACSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:R
Last Name:COLE
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 AGARD AVE
Mailing Address - Street 2:PO BOX 751
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49023-0751
Mailing Address - Country:US
Mailing Address - Phone:269-944-1747
Mailing Address - Fax:269-944-5535
Practice Address - Street 1:960 AGARD AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49023-0751
Practice Address - Country:US
Practice Address - Phone:269-944-1747
Practice Address - Fax:269-944-5535
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801083649104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker