Provider Demographics
NPI:1760559397
Name:COLES, CRAIG A
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:A
Last Name:COLES
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 1:8000 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1306
Mailing Address - Country:US
Mailing Address - Phone:804-553-3200
Mailing Address - Fax:804-553-3312
Practice Address - Street 1:8000 BROOK RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-1306
Practice Address - Country:US
Practice Address - Phone:804-553-3200
Practice Address - Fax:804-553-3312
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0-04-1543103TB0200X
VA0134000034103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0041543Medicaid