Provider Demographics
NPI:1710874946
Name:COLE, GRANT PRESTON
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:PRESTON
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 1:133 W PARK AVE APT A
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4025
Mailing Address - Country:US
Mailing Address - Phone:856-560-0906
Mailing Address - Fax:
Practice Address - Street 1:4222 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1628
Practice Address - Country:US
Practice Address - Phone:863-456-7148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician