Provider Demographics
NPI:1639661291
Name:COLE, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5648 DESERT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7238
Mailing Address - Country:US
Mailing Address - Phone:360-722-0299
Mailing Address - Fax:
Practice Address - Street 1:11650 IBERIA PL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2406
Practice Address - Country:US
Practice Address - Phone:800-434-8923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician