Provider Demographics
NPI:1598275315
Name:COLE, TINA MARIE (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:COLE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:WILKENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:195 MOUNT LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:GAINES
Mailing Address - State:PA
Mailing Address - Zip Code:16921-9530
Mailing Address - Country:US
Mailing Address - Phone:570-215-9490
Mailing Address - Fax:570-203-2293
Practice Address - Street 1:195 MOUNT LAUREL LN
Practice Address - Street 2:
Practice Address - City:GAINES
Practice Address - State:PA
Practice Address - Zip Code:16921-9530
Practice Address - Country:US
Practice Address - Phone:570-215-9490
Practice Address - Fax:570-203-2293
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009499101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104094732-000Medicaid