Provider Demographics
NPI:1619528353
Name:STASEK, COLE CAMERON (AUD)
Entity Type:Individual
Prefix:DR
First Name:COLE
Middle Name:CAMERON
Last Name:STASEK
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EXECUTIVE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2713
Mailing Address - Country:US
Mailing Address - Phone:586-945-6694
Mailing Address - Fax:
Practice Address - Street 1:100 EXECUTIVE WAY STE 100
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-2713
Practice Address - Country:US
Practice Address - Phone:586-945-6694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY2324231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist