Provider Demographics
NPI:1588029466
Name:COLE, RANDALL
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 13TH AVE.
Mailing Address - Street 2:
Mailing Address - City:LUCERNE
Mailing Address - State:CA
Mailing Address - Zip Code:95458
Mailing Address - Country:US
Mailing Address - Phone:707-274-9101
Mailing Address - Fax:
Practice Address - Street 1:991 PARALLEL DR
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5720
Practice Address - Country:US
Practice Address - Phone:707-274-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)