Provider Demographics
NPI:1558496935
Name:COLE, KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1123
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CA
Mailing Address - Zip Code:95570-1123
Mailing Address - Country:US
Mailing Address - Phone:707-599-2856
Mailing Address - Fax:
Practice Address - Street 1:830 G ST STE 210
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6256
Practice Address - Country:US
Practice Address - Phone:707-599-2856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical