Provider Demographics
NPI:1568472397
Name:COLE, CHARLES SANDFORD (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SANDFORD
Last Name:COLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 VAUGHAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3204
Mailing Address - Country:US
Mailing Address - Phone:207-662-6221
Mailing Address - Fax:207-662-3262
Practice Address - Street 1:216 VAUGHAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3204
Practice Address - Country:US
Practice Address - Phone:207-662-6221
Practice Address - Fax:207-662-3262
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS582103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM568701Medicare PIN
MEMM5687Medicare PIN