Provider Demographics
NPI:1821419409
Name:COLE, WESLEY
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
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 1:100 VETERANS WAY
Mailing Address - Street 2:
Mailing Address - City:EGLIN
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1038
Mailing Address - Country:US
Mailing Address - Phone:850-609-2604
Mailing Address - Fax:
Practice Address - Street 1:100 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:EGLIN
Practice Address - State:FL
Practice Address - Zip Code:32542-1038
Practice Address - Country:US
Practice Address - Phone:850-609-2604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1302483104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker