Provider Demographics
NPI:1750027751
Name:COLE, SHANTYL RENEE (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:SHANTYL
Middle Name:RENEE
Last Name:COLE
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FREDERICK CT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2518
Mailing Address - Country:US
Mailing Address - Phone:304-888-9388
Mailing Address - Fax:
Practice Address - Street 1:103 FREDERICK CT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2518
Practice Address - Country:US
Practice Address - Phone:304-888-9388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP009442281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical