Provider Demographics
NPI:1548793482
Name:COLE, JOHNNY SR (CASAC)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:COLE
Suffix:SR
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 JONES AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-1252
Mailing Address - Country:US
Mailing Address - Phone:585-719-8523
Mailing Address - Fax:585-719-8526
Practice Address - Street 1:24 JONES AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-1252
Practice Address - Country:US
Practice Address - Phone:585-719-8523
Practice Address - Fax:585-719-8526
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10911101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)