Provider Demographics
NPI:1720411515
Name:COLE, KIANNA MONIQUE (LCSW)
Entity Type:Individual
Prefix:
First Name:KIANNA
Middle Name:MONIQUE
Last Name:COLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 MONTGOMERY ST
Mailing Address - Street 2:P.O. BOX 608
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2923
Mailing Address - Country:US
Mailing Address - Phone:315-435-3739
Mailing Address - Fax:315-435-3360
Practice Address - Street 1:421 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2923
Practice Address - Country:US
Practice Address - Phone:315-435-3739
Practice Address - Fax:315-435-3360
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088925104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00569860Medicaid
NY536220Medicaid