Provider Demographics
NPI:1568515435
Name:COLE, THERESA GRACE (LCSW, ACSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:GRACE
Last Name:COLE
Suffix:
Gender:F
Credentials:LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5802 CARL ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-2802
Mailing Address - Country:US
Mailing Address - Phone:318-787-2283
Mailing Address - Fax:
Practice Address - Street 1:1412 PETERMAN DR
Practice Address - Street 2:SUITE A
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3432
Practice Address - Country:US
Practice Address - Phone:318-787-6805
Practice Address - Fax:318-787-6818
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1568515435Medicare NSC